Provider Demographics
NPI:1568690832
Name:KIM, KENNETH PAK (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PAK
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2540 WINDY HILL RD SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8605
Mailing Address - Country:US
Mailing Address - Phone:470-644-1274
Mailing Address - Fax:470-644-1119
Practice Address - Street 1:2540 WINDY HILL RD SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8605
Practice Address - Country:US
Practice Address - Phone:470-644-1274
Practice Address - Fax:470-644-1119
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD29309207L00000X
GA97909207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP00826857OtherRAILROAD MEDICARE
OR500612003Medicaid
WA8552531Medicaid
ORR148230Medicare PIN
ORR148229Medicare PIN
WA8552531Medicaid