Provider Demographics
NPI:1104883768
Name:KIM, CHANG KWON (MD,FACS)
Entity type:Individual
Prefix:
First Name:CHANG
Middle Name:KWON
Last Name:KIM
Suffix:
Gender:M
Credentials:MD,FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 546
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-0546
Mailing Address - Country:US
Mailing Address - Phone:630-208-1700
Mailing Address - Fax:630-208-1707
Practice Address - Street 1:0N300 ARMSTRONG LN
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-6081
Practice Address - Country:US
Practice Address - Phone:630-208-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036060318208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060318Medicaid
ILD14291Medicare UPIN