Provider Demographics
NPI:1477118883
Name:SUNG, AUDREY SOOJUNG
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:SOOJUNG
Last Name:SUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7411 LAKE ST
Mailing Address - Street 2:STE 1120
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1882
Mailing Address - Country:US
Mailing Address - Phone:708-783-2328
Mailing Address - Fax:708-345-9984
Practice Address - Street 1:600 S PAULINA ST STE 403
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3806
Practice Address - Country:US
Practice Address - Phone:312-942-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-01
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.077945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty