Provider Demographics
NPI:1760450290
Name:KIM, KYU (MD)
Entity Type:Individual
Prefix:
First Name:KYU
Middle Name:
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 1:5223 W BRIARSTONE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-8623
Mailing Address - Country:US
Mailing Address - Phone:309-282-0827
Mailing Address - Fax:309-683-1003
Practice Address - Street 1:7309 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2085
Practice Address - Country:US
Practice Address - Phone:309-282-0827
Practice Address - Fax:309-683-1003
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC42563Medicare UPIN
ILK02035Medicare ID - Type Unspecified