Provider Demographics
NPI:1225055866
Name:KIM, JAE H (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:H
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 1:10400 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-1367
Mailing Address - Country:US
Mailing Address - Phone:708-423-8706
Mailing Address - Fax:708-423-8659
Practice Address - Street 1:10400 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-1367
Practice Address - Country:US
Practice Address - Phone:708-423-8706
Practice Address - Fax:708-423-8659
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 096031208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036096031Medicaid
L73141Medicare UPIN
211475Medicare PIN
IL036096031Medicaid