Provider Demographics
NPI:1588198626
Name:KIM, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:HOMETOWN
Mailing Address - State:IL
Mailing Address - Zip Code:60456-1135
Mailing Address - Country:US
Mailing Address - Phone:708-422-5700
Mailing Address - Fax:708-422-8225
Practice Address - Street 1:4140 SOUTHWEST HWY
Practice Address - Street 2:
Practice Address - City:HOMETOWN
Practice Address - State:IL
Practice Address - Zip Code:60456-1135
Practice Address - Country:US
Practice Address - Phone:708-422-5700
Practice Address - Fax:708-422-8225
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-15
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.072376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine