Provider Demographics
NPI:1457567836
Name:KIM, EDWARD TAE
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:TAE
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EDWARD
Other - Middle Name:TAE
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:658 N BLACK HORSE PK
Mailing Address - Street 2:
Mailing Address - City:RUNNEMEDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08078
Mailing Address - Country:US
Mailing Address - Phone:856-939-3405
Mailing Address - Fax:856-939-0104
Practice Address - Street 1:658 N BLACK HORSE PK
Practice Address - Street 2:
Practice Address - City:RUNNEMEDE
Practice Address - State:NJ
Practice Address - Zip Code:08078
Practice Address - Country:US
Practice Address - Phone:856-939-3405
Practice Address - Fax:856-939-0104
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11227208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice