Basic Information
| Provider Information | |||||||||
| NPI: | 1316981491 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | JAE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7309 N KNOXVILLE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616142085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096916225 | ||||||||
| FaxNumber: | 3096917635 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 W WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 615202444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096475240 | ||||||||
| FaxNumber: | 3096475104 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 05/04/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036056328 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036056328 | 05 | IL | MEDICAID | P00945642 | 01 | IL | RAILROAD MEDICARE PTAN | OTHER |