Provider Demographics
NPI:1881616894
Name:KIM, EDMUND A (MD)
Entity type:Individual
Prefix:
First Name:EDMUND
Middle Name:A
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 1:99 WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1207
Mailing Address - Country:US
Mailing Address - Phone:860-714-4212
Mailing Address - Fax:860-714-8080
Practice Address - Street 1:99 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1207
Practice Address - Country:US
Practice Address - Phone:860-714-4212
Practice Address - Fax:860-714-8080
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041333207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080001789OtherMEDICARE ID
CT1413335Medicaid
CT1413335Medicaid