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General NPI Number Information
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NPI Number | 1710928627
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Entity Type | Organization
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Legal Business Name | JAE KIM, M.D.
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Dates
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Enumeration Date | 06/10/2006
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Last Update Date | 05/01/2015
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Provider Practice Location Address
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Address Line | 210 W WALNUT ST
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City | CANTON
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State | IL
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Zip | 61520-2444
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Country | US
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Telephone | 309-647-5240
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Fax | 309-647-5104
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Provider Business Mailing Address
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Address Line | 7309 N KNOXVILLE AVE SUITE 200
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City | PEORIA
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State | IL
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Zip | 61614-2085
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Country | US
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Telephone | 309-691-6225
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Fax | 309-691-7635
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Authorized Official
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Title or Position | OWNER
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Name | JAE K KIM
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Credential | M.D.
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Telephone | 309-671-8749
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 036056328
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License Number State | IL
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