Provider Demographics
NPI:1811137243
Name:PU WOONG KIM,MD,.SC
Entity type:Organization
Organization Name:PU WOONG KIM,MD,.SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OF PU WOOG KIM,MD,.SC
Authorized Official - Prefix:DR
Authorized Official - First Name:PU
Authorized Official - Middle Name:WOONG
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-561-1554
Mailing Address - Street 1:5140 N CALIFORNIA AVE
Mailing Address - Street 2:SUITE 715
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3645
Mailing Address - Country:US
Mailing Address - Phone:773-561-1554
Mailing Address - Fax:773-561-1586
Practice Address - Street 1:5140 N CALIFORNIA AVE
Practice Address - Street 2:SUITE 715
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3645
Practice Address - Country:US
Practice Address - Phone:773-561-1554
Practice Address - Fax:773-561-1586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-047684261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047684Medicaid