Basic Information
Provider Information | |||||||||
NPI: | 1962472589 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIM | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | PETER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 824 ILLINOIS AVE | ||||||||
Address2: |   | ||||||||
City: | STEVENS POINT | ||||||||
State: | WI | ||||||||
PostalCode: | 544813112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7153465000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2801 W KINNICKINNIC RIVER PKWY STE 1080 | ||||||||
Address2: |   | ||||||||
City: | MILWAUKEE | ||||||||
State: | WI | ||||||||
PostalCode: | 532153689 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4149086601 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/25/2006 | ||||||||
LastUpdateDate: | 12/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | JK079482 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207RG0100X | 38289-20 | WI | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 1105202081 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 34100400 | 05 | WI |   | MEDICAID | 4437305 | 05 | MI |   | MEDICAID | 100017318 | 01 | MI | RAILROAD MEDICARE | OTHER |