Provider Demographics
NPI:1992896674
Name:KIM, AE CHAN (MD)
Entity type:Individual
Prefix:
First Name:AE
Middle Name:CHAN
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 1:43 TWEED BLVD
Mailing Address - Street 2:
Mailing Address - City:NYACK,
Mailing Address - State:NY
Mailing Address - Zip Code:10960
Mailing Address - Country:US
Mailing Address - Phone:845-634-1799
Mailing Address - Fax:845-358-6604
Practice Address - Street 1:43 TWEED BLVD
Practice Address - Street 2:
Practice Address - City:NYACK,
Practice Address - State:NY
Practice Address - Zip Code:10960
Practice Address - Country:US
Practice Address - Phone:845-634-1799
Practice Address - Fax:845-358-6604
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117579208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY117579OtherLICENSE
NY00218277Medicaid
A63961Medicare UPIN
NY117579OtherLICENSE