Provider Demographics
NPI:1609132984
Name:KIM, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KIM
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 1:1901 W. HARRISON ST.
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-9985
Mailing Address - Country:US
Mailing Address - Phone:312-864-0394
Mailing Address - Fax:
Practice Address - Street 1:1901 W. HARRISON ST.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-9985
Practice Address - Country:US
Practice Address - Phone:312-864-0394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-139633207PT0002X
IL36139633207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology