Provider Demographics
NPI:1801995113
Name:KIM, KILJUNG KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:KILJUNG
Middle Name:KENNETH
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 597903
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-7903
Mailing Address - Country:US
Mailing Address - Phone:815-941-1317
Mailing Address - Fax:815-941-1421
Practice Address - Street 1:8012 S CRANDON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1124
Practice Address - Country:US
Practice Address - Phone:773-356-5381
Practice Address - Fax:773-356-5186
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036047946207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047946Medicaid
IL1626751OtherBLUE CROSS BLUE SHIELD
IL036047946Medicaid