Provider Demographics
NPI:1003047267
Name:KENNEDY KIM, RAELENE D (MD)
Entity type:Individual
Prefix:
First Name:RAELENE
Middle Name:D
Last Name:KENNEDY KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RAELENE
Other - Middle Name:D
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:351 DELNOR DR STE 400
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-4228
Mailing Address - Country:US
Mailing Address - Phone:630-668-0833
Mailing Address - Fax:630-208-4373
Practice Address - Street 1:351 DELNOR DR STE 400
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4228
Practice Address - Country:US
Practice Address - Phone:630-668-0833
Practice Address - Fax:630-208-4373
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1485732086S0102X, 208600000X
IL0361485732086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN020003099Medicare PIN