Basic Information
Provider Information
NPI: 1962634519
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KIM
FirstName: KEVIN
MiddleName: SEUNGIL
NamePrefix:  
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 611 W. PARK ST.
Address2: BWPC
City: URBANA
State: IL
PostalCode: 618012500
CountryCode: US
TelephoneNumber: 2173836792
FaxNumber:  
Practice Location
Address1: 1818 E WINDSOR RD
Address2:  
City: URBANA
State: IL
PostalCode: 618029566
CountryCode: US
TelephoneNumber: 2172559670
FaxNumber: 2172559724
Other Information
ProviderEnumerationDate: 08/17/2009
LastUpdateDate: 05/26/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X036126940ILY Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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