Basic Information
| Provider Information | |||||||||
| NPI: | 1619098571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHOI | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W 22ND ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305755000 | ||||||||
| FaxNumber: | 7083862839 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 W 86TH AVE | ||||||||
| Address2: | NANI, LTD | ||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464107086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197911555 | ||||||||
| FaxNumber: | 2197911560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2007 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 036111704 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RN0300X | 01063644A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 628850 | 01 | IN | MEDICARE GROUP | OTHER | 200876580 | 05 | IN | MEDICAID | 100082060 | 01 | IN | MEDICAID GROUP | OTHER | 000000536207 | 01 | IN | ANTHEM BCBS | OTHER |