Basic Information
| Provider Information | |||||||||
| NPI: | 1609940113 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | DAEWHAN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162436 | ||||||||
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| Practice Location | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 2799 WEST GRAND BOULEVARD | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139162436 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 4301066691 | MI | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | 4301066691 | MI | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 250Q260840 | 01 | BLUE CROSS-BLUE CROSS | OTHER | DK066691 | 01 | CHAMPUS-CHAMPUS | OTHER | DK066691 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | 447344610 | 05 | MI | MEDICAID |