Provider Demographics
NPI:1962472589
Name:KIM, JOSEPH PETER (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:PETER
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 1:824 ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-3112
Mailing Address - Country:US
Mailing Address - Phone:715-346-5000
Mailing Address - Fax:
Practice Address - Street 1:2801 W KINNICKINNIC RIVER PKWY STE 1080
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3689
Practice Address - Country:US
Practice Address - Phone:414-908-6601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJK079482207RG0100X
WI38289-20207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1105202081OtherBLUE CROSS BLUE SHIELD
WI34100400Medicaid
MI4437305Medicaid
MI100017318OtherRAILROAD MEDICARE
WI000344070Medicare PIN
WI34100400Medicaid
MI0N83900004Medicare PIN