Provider Demographics
NPI:1396873170
Name:HYETAE KIM, MD, PA
Entity type:Organization
Organization Name:HYETAE KIM, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MGR.
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGGERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-550-5300
Mailing Address - Street 1:1157 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7723
Mailing Address - Country:US
Mailing Address - Phone:432-550-5300
Mailing Address - Fax:432-687-6299
Practice Address - Street 1:1157 E 42ND ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-7723
Practice Address - Country:US
Practice Address - Phone:432-550-5300
Practice Address - Fax:432-687-6299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158174601Medicaid
TX0017JKOtherBCBS GROUP NUMBER
TX158174601Medicaid
TX158174601Medicaid
TX=========OtherTAX ID NUMBER