Provider Demographics
NPI:1780047076
Name:KIM, TAE (MD)
Entity Type:Individual
Prefix:
First Name:TAE
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 1:1459 W TAYLOR ST APT 3R
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4633
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:ROOM 4807
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-975-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL125068738208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program