Provider Demographics
NPI:1306866124
Name:KIM, TONG SU (MD)
Entity Type:Individual
Prefix:
First Name:TONG
Middle Name:SU
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 1:3434 W PETERSON AVE
Mailing Address - Street 2:1C
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659
Mailing Address - Country:US
Mailing Address - Phone:773-267-8060
Mailing Address - Fax:847-251-7177
Practice Address - Street 1:3434 W PETERSON AVE
Practice Address - Street 2:1C
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659
Practice Address - Country:US
Practice Address - Phone:773-267-8060
Practice Address - Fax:847-251-7177
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037885208000000X
CAA33664208000000X
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
21607071OtherBCBS
493260Medicare ID - Type Unspecified
21607071OtherBCBS