Basic Information
| Provider Information | |||||||||
| NPI: | 1003045600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANG | ||||||||
| FirstName: | MINA | ||||||||
| MiddleName: | RIM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 SANTA MONICA BLVD | ||||||||
| Address2: | PROVIDENCE ST. JOHN'S HEALTH CENTER | ||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108298858 | ||||||||
| FaxNumber: | 4242125921 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121 SANTA MONICA BLVD | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904042303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104531324 | ||||||||
| FaxNumber: | 4242125921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2009 | ||||||||
| LastUpdateDate: | 04/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A114952 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | A114952 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | A114952 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.