Provider Demographics
NPI:1255321873
Name:KIM, SUN-BUM (MD)
Entity Type:Individual
Prefix:
First Name:SUN-BUM
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 1:9669 KENTON AVE
Mailing Address - Street 2:STE 403
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1266
Mailing Address - Country:US
Mailing Address - Phone:847-674-4730
Mailing Address - Fax:847-674-4732
Practice Address - Street 1:9669 KENTON AVE
Practice Address - Street 2:STE 403
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1266
Practice Address - Country:US
Practice Address - Phone:847-674-4730
Practice Address - Fax:847-674-4732
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096982208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3642333916067801Medicaid
BK5885720OtherDEA
G88738Medicare UPIN
IL3642333916067801Medicaid