NPIMap

Individual provider Active NPI

John Raphael Kim, MD

  • Diagnostic Radiology Physician
  • Fort Wayne, IN
National Provider Identifier
1710958848
Registry record updated Dec 16, 2009
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
License
10142685 Issued in IN
Practice address
6119 W Jefferson Blvd
Fort Wayne, IN 46804-3072
Phone
(260) 432-1568
Fax
(260) 432-4946
NPI assigned
Jan 27, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 16, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology Physician 2085R0202X 10142685 IN Primary

Addresses

Primary practice location

6119 W Jefferson Blvd
Fort Wayne, IN 46804-3072

Mailing address

6119 W Jefferson Blvd
Fort Wayne, IN 46804-3072
Phone (260) 432-1568

Other identifiers 4

IdentifierTypeStateIssuer
300077566OtherINMEDICARE RAILROAD
0983280MedicaidOH
300039257OtherINMEDICARE RAILROAD
100376180MedicaidIN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
10142685INMDDiagnostic Radiology Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Summit Radiology P C Diagnostic Radiology Past Accepting new patients
St. Joseph Health System, LLC Past Accepting new patients
Imaging Diagnostic Center Limited Diagnostic Radiology Past Accepting new patients

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1138320000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1260921600000",
    "number": "1710958848",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6119 W JEFFERSON BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468043072",
            "telephone_number": "260-432-1568",
            "fax_number": "260-432-4946"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6119 W JEFFERSON BLVD",
            "city": "FORT WAYNE",
            "state": "IN",
            "postal_code": "468043072",
            "telephone_number": "260-432-1568",
            "fax_number": "260-432-4946"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KIM",
        "first_name": "JOHN",
        "middle_name": "RAPHAEL",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-01-27",
        "last_updated": "2009-12-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "",
            "desc": "Radiology, Diagnostic Radiology",
            "state": "IN",
            "license": "10142685",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "300077566",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0983280",
            "state": "OH"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RAILROAD",
            "identifier": "300039257",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100376180",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Wayne, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 16, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.