Provider Demographics
NPI:1538194808
Name:KIM, TAE YOUNG (PT)
Entity type:Individual
Prefix:
First Name:TAE
Middle Name:YOUNG
Last Name:KIM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6062 BUFORD HWY
Mailing Address - Street 2:SUITE 117
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-2424
Mailing Address - Country:US
Mailing Address - Phone:770-446-0111
Mailing Address - Fax:770-446-1360
Practice Address - Street 1:6062 BUFORD HWY
Practice Address - Street 2:SUITE 117
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-2424
Practice Address - Country:US
Practice Address - Phone:770-446-0111
Practice Address - Fax:770-446-1360
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAPT009506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I659696Medicare PIN
COC454688Medicare ID - Type Unspecified