Healthcare Provider Details

I. General information

NPI: 1780047076
Provider Name (Legal Business Name): TAE KIM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 PARK AVE W STE 2850
HIGHLAND PARK IL
60035-2558
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-1700
  • Fax: 224-251-5470
Mailing address:
  • Phone: 847-570-2040
  • Fax: 847-570-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036157530
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number036157530
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: