Basic Information
| Provider Information | |||||||||
| NPI: | 1306308382 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JAE KIM, MD PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 WILSON BLVD STE 102-219 | ||||||||
| Address2: | |||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 222013397 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 10721 MAIN ST STE 205 | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220306902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037052100 | ||||||||
| FaxNumber: | 7039350330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2019 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | KIM | ||||||||
| AuthorizedOfficialFirstName: | JAE | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3475511113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 207YS0123X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery |
No ID Information.