Basic Information
| Provider Information | |||||||||
| NPI: | 1780621086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | MELANIE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BOSTON MEDICAL CTR PL | ||||||||
| Address2: | DOWLING 3 SOUTH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 BOSTON MEDICAL CTR PL | ||||||||
| Address2: | DOWLING 3 SOUTH | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174145170 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173000000X | 56684 | MA | Y | Other Service Providers | Legal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3014746 | 05 | MA | MEDICAID |