Provider Demographics
NPI:1699797449
Name:KIM, CHANG SOO (MD)
Entity type:Individual
Prefix:
First Name:CHANG SOO
Middle Name:
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 1:16420 EAST 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-2442
Mailing Address - Country:US
Mailing Address - Phone:586-779-0000
Mailing Address - Fax:586-779-9866
Practice Address - Street 1:16420 EAST 9 MILE RD
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-2442
Practice Address - Country:US
Practice Address - Phone:586-779-0000
Practice Address - Fax:586-779-9866
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICK031478207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1093837Medicaid
B46944Medicare UPIN
05066699111Medicare ID - Type Unspecified