Basic Information
| Provider Information | |||||||||
| NPI: | 1821077553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 730 W MARKET ST STE 2K | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199964011 | ||||||||
| FaxNumber: | 4199964012 | ||||||||
| Practice Location | |||||||||
| Address1: | 730 W MARKET ST STE 2K | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458014602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4199964011 | ||||||||
| FaxNumber: | 4199964012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 18287 | WV | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 2493789 | 01 | OH | OH MEDICAID MOLINA | OTHER | 000000433626 | 01 | OH | OHIO MEDICAID UNISON | OTHER | 310917085258 | 01 | OH | OH MEDICAID CARESOURCE | OTHER | 0129081000 | 05 | WV | MEDICAID | 2493789 | 05 | OH | MEDICAID |