Basic Information
| Provider Information | |||||||||
| NPI: | 1750383188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | KIM-KING | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 W GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | RED BANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077014918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120051 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Practice Location | |||||||||
| Address1: | 718 TEANECK ROAD | ||||||||
| Address2: | |||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018333000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2005 | ||||||||
| LastUpdateDate: | 06/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MA03194200 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 25MA03194200 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208D00000X | 25MA03194200 | NJ | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 5425301 | 05 | NJ | MEDICAID | P00766578 | 01 | PA | RR MEDICARE | OTHER | P00674579 | 01 | NJ | RAIL ROAD MEDICARE | OTHER |