Provider Demographics
NPI:1225237704
Name:KIM, ROGER HOON (MD)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:HOON
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2520 CLAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-2387
Mailing Address - Country:US
Mailing Address - Phone:631-987-7168
Mailing Address - Fax:
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-554-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2033022086X0206X
VA01012415812086X0206X
IL036-144271208600000X, 2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-144271OtherSTATE LICENSE
LA4M318F600OtherMEDICARE - PTAN