Basic Information
Provider Information | |||||||||
NPI: | 1962439992 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIM | ||||||||
FirstName: | JEAN | ||||||||
MiddleName: | OK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 29373 NETWORK PL | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606731293 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8475783000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1675 DEMPSTER ST FL 3 | ||||||||
Address2: |   | ||||||||
City: | PARK RIDGE | ||||||||
State: | IL | ||||||||
PostalCode: | 600681110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8473189330 | ||||||||
FaxNumber: | 8477239051 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2006 | ||||||||
LastUpdateDate: | 05/25/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0208X | 036-101238 | IL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 2080P0208X | 40518 | IA | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
ID | Type | State | Issuer | Description | 347713028 | 01 | IL | PTAN MCHENRY | OTHER | 036-101238 | 05 | IL |   | MEDICAID | 347710033 | 01 | IL | PTAN COOK | OTHER | 347711014 | 01 | IL | PTAN DUPAGE | OTHER | IL3289017 | 01 | IL | PTAN WILL | OTHER |