Basic Information
| Provider Information | |||||||||
| NPI: | 1770570293 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | KIM | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1760 E RIVER RD | ||||||||
| Address2: | SUITE 350 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857185877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5205197775 | ||||||||
| FaxNumber: | 5805197910 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 E HIGHLAND AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022774868 | ||||||||
| FaxNumber: | 6022309350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2005 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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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 | 208C00000X | 33968 | AZ | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 933128 | 05 | AZ | MEDICAID |