Provider Demographics
NPI:1275586901
Name:LIM, JOHN V (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:V
Last Name:LIM
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 1:1405 HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-4832
Mailing Address - Country:US
Mailing Address - Phone:708-484-8861
Mailing Address - Fax:866-391-1683
Practice Address - Street 1:1405 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-4832
Practice Address - Country:US
Practice Address - Phone:708-484-8861
Practice Address - Fax:866-391-1683
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0868352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-086835OtherLICENSE NUMBER
IL036-086835Medicaid
IL355641Medicare ID - Type Unspecified
ILF93033Medicare UPIN