Provider Demographics
NPI:1942250030
Name:KIM, PETER S (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:S
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:P.O. BOX 9
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IL
Mailing Address - Zip Code:62249
Mailing Address - Country:US
Mailing Address - Phone:618-654-1281
Mailing Address - Fax:618-654-1452
Practice Address - Street 1:821 POPLAR ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IL
Practice Address - Zip Code:62249-1658
Practice Address - Country:US
Practice Address - Phone:618-654-1281
Practice Address - Fax:618-654-1452
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036090402207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213743OtherPTAN
IL684410Medicare UPIN