Provider Demographics
NPI:1225093750
Name:KIM, JINSUP (MD)
Entity Type:Individual
Prefix:
First Name:JINSUP
Middle Name:
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 1:1890 SILVER CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9524
Mailing Address - Country:US
Mailing Address - Phone:815-300-1450
Mailing Address - Fax:815-300-4703
Practice Address - Street 1:1890 SILVER CROSS BLVD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9524
Practice Address - Country:US
Practice Address - Phone:815-300-1450
Practice Address - Fax:815-300-4703
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2014-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059465Medicaid
IL036059465Medicaid
ILL95605Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 15
ILL95604Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 16