Provider Demographics
NPI:1902880123
Name:KIM, MARY M (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1624 MARS HILL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-4813
Mailing Address - Country:US
Mailing Address - Phone:706-310-1030
Mailing Address - Fax:706-705-1444
Practice Address - Street 1:1624 MARS HILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-4813
Practice Address - Country:US
Practice Address - Phone:706-310-1030
Practice Address - Fax:706-705-1444
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA050031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00904142AMedicaid
GA00904142AMedicaid
GA11BDSWWMedicare ID - Type Unspecified