Provider Demographics
NPI:1164055646
Name:KIM, ABRAHAM (PTA)
Entity Type:Individual
Prefix:
First Name:ABRAHAM
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 W ROSCOE ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6220
Mailing Address - Country:US
Mailing Address - Phone:773-899-4051
Mailing Address - Fax:
Practice Address - Street 1:2124 W ROSCOE ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6220
Practice Address - Country:US
Practice Address - Phone:773-899-4051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008327225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant