Provider Demographics
NPI:1821273962
Name:JONG KIM FAMILY MEDICINE
Entity Type:Organization
Organization Name:JONG KIM FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONG
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-738-3550
Mailing Address - Street 1:8777 BROADWAY
Mailing Address - Street 2:SUITE C
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6693
Mailing Address - Country:US
Mailing Address - Phone:219-738-3550
Mailing Address - Fax:219-757-6727
Practice Address - Street 1:8777 BROADWAY
Practice Address - Street 2:SUITE C
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-6693
Practice Address - Country:US
Practice Address - Phone:219-738-3550
Practice Address - Fax:219-757-6727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036861A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100200870Medicaid
INE13647Medicare UPIN
IN100200870Medicaid