Provider Demographics
NPI:1932130135
Name:KIM, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
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 1:680 N LAKE SHORE DR
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4546
Mailing Address - Country:US
Mailing Address - Phone:312-695-9797
Mailing Address - Fax:
Practice Address - Street 1:259 E ERIE ST STE 2060
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2987
Practice Address - Country:US
Practice Address - Phone:312-695-6022
Practice Address - Fax:312-695-5672
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361111692086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111169Medicaid
I16561Medicare UPIN