Healthcare Provider Details

I. General information

NPI: 1144924259
Provider Name (Legal Business Name): JISOO KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 RYAN PKWY STE 2140
ALGONQUIN IL
60102-4530
US

IV. Provider business mailing address

29373 NETWORK PL
CHICAGO IL
60673-1293
US

V. Phone/Fax

Practice location:
  • Phone: 847-658-9555
  • Fax:
Mailing address:
  • Phone: 847-390-5900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036.178291
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: