Provider Demographics
NPI:1912977034
Name:KIM, EDWIN H (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:H
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8629 SUDLEY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4590
Mailing Address - Country:US
Mailing Address - Phone:703-361-3030
Mailing Address - Fax:703-361-2687
Practice Address - Street 1:8629 SUDLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4590
Practice Address - Country:US
Practice Address - Phone:703-361-3030
Practice Address - Fax:703-361-2687
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA01012264272085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10038383Medicaid
VA10038294Medicaid
VA6688-0027OtherCAREFIRST
VA10038341Medicaid
VA10029139Medicaid
VA10038316Medicaid
VA10029139Medicaid
VA10038316Medicaid