Provider Demographics
NPI:1285175109
Name:KIM, STEPHEN (CPO)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 E 47TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-4695
Mailing Address - Country:US
Mailing Address - Phone:312-757-5270
Mailing Address - Fax:
Practice Address - Street 1:1304 E 47TH ST STE 204
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-4695
Practice Address - Country:US
Practice Address - Phone:312-757-5270
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL211.000412224P00000X
IL213.000297222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist