Healthcare Provider Details

I. General information

NPI: 1851729370
Provider Name (Legal Business Name): MIDWEST PODIATRIC PHYSICIANS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2013
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 N NORTH BRANCH ST STE 308
CHICAGO IL
60642-2473
US

IV. Provider business mailing address

1229 N NORTH BRANCH ST STE 308
CHICAGO IL
60642-2473
US

V. Phone/Fax

Practice location:
  • Phone: 847-912-9202
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016005437
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number016005437
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number016005437
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005437
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number016005437
License Number StateIL

VIII. Authorized Official

Name: DR. SUJIN KIM
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 847-912-9202