Basic Information
| Provider Information | |||||||||
| NPI: | 1275531907 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JENNY | ||||||||
| MiddleName: | CHRISTINE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | NORTHSIDE HOSPITAL- MANAGED CARE DEPT | ||||||||
| Address2: | 1000 JOHNSON FERRY RD | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042974230 | ||||||||
| FaxNumber: | 4042974252 | ||||||||
| Practice Location | |||||||||
| Address1: | 484 IRVIN CT | ||||||||
| Address2: | STE 140 | ||||||||
| City: | DECATUR | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300305406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4042974230 | ||||||||
| FaxNumber: | 4042974252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 01/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0012X | 054440 | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine | 207Y00000X | 054440 | GA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 862450770C | 05 | GA | MEDICAID | 862450770W | 05 | GA | MEDICAID | 862450770B | 05 | GA | MEDICAID | 862450770U | 05 | GA | MEDICAID | 862450770A | 05 | GA | MEDICAID | 862450770D | 05 | GA | MEDICAID |