Provider Demographics
NPI:1528174117
Name:KIM, SHELLEY E (MD)
Entity type:Individual
Prefix:DR
First Name:SHELLEY
Middle Name:E
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3367 BUFORD HWY NE
Mailing Address - Street 2:SUITE 910
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-1833
Mailing Address - Country:US
Mailing Address - Phone:678-843-8700
Mailing Address - Fax:404-633-0502
Practice Address - Street 1:3367 BUFORD HWY NE
Practice Address - Street 2:SUITE 910
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-1833
Practice Address - Country:US
Practice Address - Phone:678-843-8700
Practice Address - Fax:404-633-0502
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA52763208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA977586582BMedicaid
GA977586582CMedicaid