Basic Information
| Provider Information | |||||||||
| NPI: | 1760409262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | Y | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 S MILWAUKEE ROAD | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473622900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 S MILWAUKEE ROAD | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473622900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 036084541 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0360845411 | 05 | IL | MEDICAID |