MEDICARE: MRS. SO J KIM MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207L00000X	Anesthesiology Physician	036-055406	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01638884	OTHER	IL	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235122201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SO J KIM MD

Provider Business Mailing Address
First Line	:	47 DEVONSHIRE DR
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-1712
Country	:	US
Telephone Number	:	630-887-0031
Fax Number	:	630-887-0031

Provider Business Practice Location Address
First Line	:	1044 N FRANCISCO AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60622-2743
Country	:	US
Telephone Number	:	773-292-8200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2005
Last Update Date	:	07/21/2008

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