Provider Demographics
NPI:1477588580
Name:KIM, PU WOONG (MD SC)
Entity Type:Individual
Prefix:DR
First Name:PU
Middle Name:WOONG
Last Name:KIM
Suffix:
Gender:M
Credentials:MD SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 N CALIFORNIA
Mailing Address - Street 2:SUITE 715
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5140 N CALIFORNIA
Practice Address - Street 2:SUITE 715
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625
Practice Address - Country:US
Practice Address - Phone:773-561-1554
Practice Address - Fax:773-561-1586
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21625149OtherBLUE CROSS BLUE SHIELD
ILAK5788762OtherPHARMACY DEA
D12819Medicare UPIN