Basic Information
Provider Information | |||||||||
NPI: | 1598841447 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIM | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | W. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 325 MAINE STREET | ||||||||
Address2: | MSO LIBRARY | ||||||||
City: | LAWRENCE | ||||||||
State: | KS | ||||||||
PostalCode: | 66044 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7855052988 | ||||||||
FaxNumber: | 7855055228 | ||||||||
Practice Location | |||||||||
Address1: | 330 ARKANSAS ST STE 215 | ||||||||
Address2: |   | ||||||||
City: | LAWRENCE | ||||||||
State: | KS | ||||||||
PostalCode: | 660441326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7855052250 | ||||||||
FaxNumber: | 7855055259 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/31/2006 | ||||||||
LastUpdateDate: | 11/02/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/01/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 2016008069 | MO | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | G84630 | CA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 04-38712 | KS | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 30004011590001 | 05 | KS |   | MEDICAID | 1598841447 | 05 | MO |   | MEDICAID |