Provider Demographics
NPI:1154361434
Name:KIM, CHARLES S (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11839
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55111-0839
Mailing Address - Country:US
Mailing Address - Phone:984-377-3422
Mailing Address - Fax:855-740-1940
Practice Address - Street 1:631 CLEVELAND AVE S STE 5
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55116-1244
Practice Address - Country:US
Practice Address - Phone:984-377-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41236174400000X, 208100000X
MN57253208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
3060128Medicare PIN