Healthcare Provider Details

I. General information

NPI: 1831391689
Provider Name (Legal Business Name): CHANG K KIM MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

0N300 ARMSTRONG LN
GENEVA IL
60134-6081
US

IV. Provider business mailing address

PO BOX 546
ST CHARLES IL
60174-0546
US

V. Phone/Fax

Practice location:
  • Phone: 630-208-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036060318
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036060318
License Number StateIL

VIII. Authorized Official

Name: CHANG K KIM
Title or Position: OWNER
Credential:
Phone: 630-208-1700