Provider Demographics
NPI:1306308382
Name:JAE KIM, MD PLC
Entity type:Organization
Organization Name:JAE KIM, MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:347-551-1113
Mailing Address - Street 1:2200 WILSON BLVD STE 102-219
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-3397
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10721 MAIN ST STE 205
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6902
Practice Address - Country:US
Practice Address - Phone:703-705-2100
Practice Address - Fax:703-935-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-01
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty