Provider Demographics
NPI:1689612905
Name:KIM, SOO Y (MD)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:Y
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5133
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60680-5133
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:934 CENTER ST
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2125
Practice Address - Country:US
Practice Address - Phone:847-742-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360487431Medicaid
ILC51538Medicare UPIN
ILL82879Medicare ID - Type Unspecified