Provider Demographics
NPI:1356458673
Name:KIM, MICHELLE M (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:M
Last Name:KIM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14236 MCCARTHY ROAD
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439
Mailing Address - Country:US
Mailing Address - Phone:630-863-7517
Mailing Address - Fax:630-863-7519
Practice Address - Street 1:14236 MCCARTHY ROAD
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439
Practice Address - Country:US
Practice Address - Phone:630-863-7517
Practice Address - Fax:630-863-7519
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016-005207213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005207Medicaid
IL016005207Medicaid
ILK45288Medicare PIN