Healthcare Provider Details

I. General information

NPI: 1164004206
Provider Name (Legal Business Name): JI WON KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2021
Last Update Date: 07/21/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 STATE ST
SPRINGFIELD MA
01109-4140
US

IV. Provider business mailing address

350 N CLARK ST STE 600
CHICAGO IL
60654-4782
US

V. Phone/Fax

Practice location:
  • Phone: 312-768-0965
  • Fax:
Mailing address:
  • Phone: 312-274-4580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1859098
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: