Provider Demographics
NPI:1174792154
Name:KIM, DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
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 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:250 BMH PHYSICIANS OFFICE BLDG
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5904
Practice Address - Country:US
Practice Address - Phone:865-980-5244
Practice Address - Fax:865-980-5245
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD541612086S0129X, 208600000X
OH0911002086S0129X
KY416482086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ022093Medicaid
TN103I770412Medicare PIN
OH2850900Medicaid
KY7100046080Medicaid
KY7100056850Medicaid
IN200905960Medicaid
KY1174792154Medicare NSC