Provider Demographics
NPI:1669436986
Name:KIM, MICHAEL C (PT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:KIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:758 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-3385
Mailing Address - Country:US
Mailing Address - Phone:678-985-7190
Mailing Address - Fax:678-985-7158
Practice Address - Street 1:758 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-3385
Practice Address - Country:US
Practice Address - Phone:678-985-7190
Practice Address - Fax:678-985-7158
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0078022251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBCSMMedicare ID - Type Unspecified
GAQ30076Medicare UPIN