Provider Demographics
NPI:1083606560
Name:KIM, JENNIFER J (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:J
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 1:2801 LAKESIDE DR STE 209
Mailing Address - Street 2:
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1271
Mailing Address - Country:US
Mailing Address - Phone:847-562-1410
Mailing Address - Fax:847-562-0830
Practice Address - Street 1:1000 CENTRAL ST STE 717
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1779
Practice Address - Country:US
Practice Address - Phone:847-864-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036102320207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK28735Medicare PIN
ILH20601Medicare UPIN
ILK28734Medicare PIN