Provider Demographics
NPI:1235122201
Name:KIM, SO J (MD)
Entity type:Individual
Prefix:MRS
First Name:SO
Middle Name:J
Last Name:KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 DEVONSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1712
Mailing Address - Country:US
Mailing Address - Phone:630-887-0031
Mailing Address - Fax:630-887-0031
Practice Address - Street 1:1044 N FRANCISCO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-2743
Practice Address - Country:US
Practice Address - Phone:773-292-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-055406207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01638884OtherBLUE CROSS BLUE SHIELD
IL036055406Medicaid
IL036055406Medicaid
ILD14969Medicare UPIN