Provider Demographics
NPI:1285737700
Name:LISA KIM MEDICAL ASSOCIATES SC
Entity type:Organization
Organization Name:LISA KIM MEDICAL ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:S
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-296-1200
Mailing Address - Street 1:2604 DEMPSTER ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-8427
Mailing Address - Country:US
Mailing Address - Phone:847-296-1200
Mailing Address - Fax:847-296-7913
Practice Address - Street 1:2604 DEMPSTER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-8427
Practice Address - Country:US
Practice Address - Phone:847-296-1200
Practice Address - Fax:847-296-7913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01620216OtherBCBS
IL01620216OtherBCBS
L38417Medicare UPIN