Basic Information
| Provider Information | |||||||||
| NPI: | 1124014642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | SUE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35422 EAGLE WAY | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606781354 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3633 W LAKE AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | GLENVIEW | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600265805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477299122 | ||||||||
| FaxNumber: | 8477299134 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2005 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YP0228X | 036-109449 | IL | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Pediatric Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 036-109449 | 05 | IL | MEDICAID |