Provider Demographics
NPI:1912069329
Name:KIM, ELLEN H (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:H
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:S
Other - Last Name:HWANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6431 SACKETT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149
Mailing Address - Country:US
Mailing Address - Phone:267-448-4908
Mailing Address - Fax:267-297-3950
Practice Address - Street 1:6431 SACKETT ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149
Practice Address - Country:US
Practice Address - Phone:267-448-4908
Practice Address - Fax:267-297-3950
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430049207Q00000X
PAMT184670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine