Provider Demographics
NPI:1831391689
Name:CHANG K KIM MD PC
Entity type:Organization
Organization Name:CHANG K KIM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANG
Authorized Official - Middle Name:K
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-208-1700
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-0546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:0N300 ARMSTRONG LN
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-6081
Practice Address - Country:US
Practice Address - Phone:630-208-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360603182086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060318Medicaid
IL020019386OtherRAILROAD MEDICARE
IL02201303OtherBLUE CROSS BLUE SHIELD
IL036060318Medicaid