Healthcare Provider Details

I. General information

NPI: 1982028130
Provider Name (Legal Business Name): AMY KIM YETASOOK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 02/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 W PARK ST GRADUATE MEDICAL EDUCATION DEPARTMENT
URBANA IL
61801-2500
US

IV. Provider business mailing address

2114 W DIVISION ST #3
CHICAGO IL
60622-3035
US

V. Phone/Fax

Practice location:
  • Phone: 217-326-1293
  • Fax:
Mailing address:
  • Phone: 213-268-5421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number125063845
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: