Provider Demographics
NPI:1003914771
Name:KIM, MIN KYUNG (MD)
Entity Type:Individual
Prefix:
First Name:MIN
Middle Name:KYUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 SCHILLER
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126
Mailing Address - Country:US
Mailing Address - Phone:331-221-9095
Mailing Address - Fax:331-221-3996
Practice Address - Street 1:1200 S. YORK
Practice Address - Street 2:#3160
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126
Practice Address - Country:US
Practice Address - Phone:331-221-9095
Practice Address - Fax:331-221-3996
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036116817208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036116817Medicaid
IL036116817Medicaid
ILK30567Medicare PIN