Provider Demographics
NPI:1215918479
Name:KIM, CHANGHEE (MD)
Entity type:Individual
Prefix:DR
First Name:CHANGHEE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHANGHEE
Other - Middle Name:KIM
Other - Last Name:HONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38815 DEQUINDRE RD
Mailing Address - Street 2:STE 103
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083
Mailing Address - Country:US
Mailing Address - Phone:248-740-7771
Mailing Address - Fax:248-740-7772
Practice Address - Street 1:38815 DEQUINDRE RD
Practice Address - Street 2:STE 103
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083
Practice Address - Country:US
Practice Address - Phone:248-740-7771
Practice Address - Fax:248-740-7772
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4562401Medicaid
MI0N12290Medicare PIN
MI0N82980Medicare PIN
MI4562401Medicaid