Provider Demographics
NPI:1790899755
Name:KIM, JAE SUK (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:SUK
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24025 GREATER MACK
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ST CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080
Mailing Address - Country:US
Mailing Address - Phone:586-777-8280
Mailing Address - Fax:586-777-8688
Practice Address - Street 1:24025 GREATER MACK
Practice Address - Street 2:SUITE 103
Practice Address - City:ST CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-777-8280
Practice Address - Fax:586-777-8688
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301033045208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1947637Medicaid
MI1947637Medicaid