Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 036060318 | IL |
Y | 208600000X | Surgeon | 036060318 | IL |
N | 2086S0129X | Vascular Surgeon | 036060318 | IL |
NPI | 1104883768 |
---|---|
Provider Name | Chang Kwon Kim |
First Address | St Charles, IL 60174-0546 |
Second Address | Geneva, IL 60134-6081 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2006 |
Last Update Date | 12/02/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036060318 | (05) | IL |
D14291 | (02) | IL |