Provider Demographics
NPI:1700822541
Name:KIM, SUNG SUP (MD)
Entity Type:Individual
Prefix:
First Name:SUNG
Middle Name:SUP
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 1:5140 N CALIFORNIA AVE
Mailing Address - Street 2:SUITE G 465
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3645
Mailing Address - Country:US
Mailing Address - Phone:773-271-8700
Mailing Address - Fax:773-271-5912
Practice Address - Street 1:5140 N CALIFORNIA AVE
Practice Address - Street 2:SUITE 465-GMP
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3645
Practice Address - Country:US
Practice Address - Phone:773-271-8700
Practice Address - Fax:773-271-5912
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-078576207RC0000X
IL036078576207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
080066025OtherRAILROAD MEDICARE PTAN#
DF8696OtherRAILROAD MEDICARE PTAN#
ILK39415OtherMEDICARE ID
IL036078576Medicaid
IL31604584OtherBCBS
DF8696OtherRAILROAD MEDICARE PTAN#