Provider Demographics
NPI:1821127804
Name:KO, MICHAEL KIM (MD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KIM
Last Name:KO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10117
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930-0117
Mailing Address - Country:US
Mailing Address - Phone:662-455-9595
Mailing Address - Fax:
Practice Address - Street 1:1401 RIVER RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-4030
Practice Address - Country:US
Practice Address - Phone:662-459-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSH14603Medicare UPIN