Healthcare Provider Details

I. General information

NPI: 1356511166
Provider Name (Legal Business Name): JANE C KIM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 05/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 W CURTIS ROAD FAMILY MEDICINE/CONVENIENT CARE
CHAMPAIGN IL
61822
US

IV. Provider business mailing address

611 W PARK ST BWPC
URBANA IL
61801-2529
US

V. Phone/Fax

Practice location:
  • Phone: 217-365-6201
  • Fax: 217-326-1234
Mailing address:
  • Phone: 217-383-6792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036121321
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number01064244A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036121321
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: