Provider Demographics
NPI:1790779791
Name:KIM, STANLEY T (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:T
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 1:2300 CHILDREN'S PLAZA, NO. 9
Mailing Address - Street 2:CHILDREN'S MEMORIAL HOSPITAL
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3363
Mailing Address - Country:US
Mailing Address - Phone:773-880-6792
Mailing Address - Fax:773-880-3517
Practice Address - Street 1:2300 CHILDREN'S PLAZA, NO. 9
Practice Address - Street 2:CHILDREN'S MEMORIAL HOSPITAL
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:773-880-6792
Practice Address - Fax:773-880-3517
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1111782085R0202X
IL036.1111782085R0202X
CA1518872085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL021622158OtherCMMG BLUE SHIELD
IL036111178Medicaid
ILI41096Medicare UPIN
IL021622158OtherCMMG BLUE SHIELD
ILL21560Medicare ID - Type UnspecifiedCOOK CNTY MDCR