Provider Demographics
NPI:1831368141
Name:KYO A KIM M.D. P.A.
Entity type:Organization
Organization Name:KYO A KIM M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOLTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-623-2018
Mailing Address - Street 1:774 CHRISTIANA ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713
Mailing Address - Country:US
Mailing Address - Phone:302-623-4004
Mailing Address - Fax:302-623-4083
Practice Address - Street 1:774 CHRISTIANA ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-623-4004
Practice Address - Fax:302-623-4083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10000868208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DED01070Medicare UPIN
DEG01383Medicare PIN