Provider Demographics
NPI:1841426400
Name:KIM, JAE H (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:H
Last Name:KIM
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 1:115 2ND AVE S APT 1415
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-2021
Mailing Address - Country:US
Mailing Address - Phone:201-952-0584
Mailing Address - Fax:
Practice Address - Street 1:909 FULTON ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-672-7422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD101132084V0102X, 2084N0400X
MN586032084N0400X, 2085R0204X, 2084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology