Provider Demographics
NPI:1316981491
Name:KIM, JAE K (MD)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:K
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:7309 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2085
Mailing Address - Country:US
Mailing Address - Phone:309-691-6225
Mailing Address - Fax:309-691-7635
Practice Address - Street 1:210 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2444
Practice Address - Country:US
Practice Address - Phone:309-647-5240
Practice Address - Fax:309-647-5104
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2015-05-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036056328207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056328Medicaid
ILP00945642OtherRAILROAD MEDICARE PTAN
ILP00945642OtherRAILROAD MEDICARE PTAN
ILC39993Medicare UPIN
IL036056328Medicaid