Provider Demographics
NPI:1821127192
Name:KIM, JUNG TAE (PT)
Entity Type:Individual
Prefix:MR
First Name:JUNG
Middle Name:TAE
Last Name:KIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 OVERBROOK AVE
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-5528
Mailing Address - Country:US
Mailing Address - Phone:732-572-7380
Mailing Address - Fax:
Practice Address - Street 1:210 WEST ST. GEORGES AVE
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:NJ
Practice Address - Zip Code:07036
Practice Address - Country:US
Practice Address - Phone:908-587-1624
Practice Address - Fax:908-587-1628
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2017-03-01
Deactivation Date:2017-02-27
Deactivation Code:
Reactivation Date:2017-03-01
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00148400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist