Provider Demographics
NPI:1174152516
Name:KIM, TAEHAN P (MD, PHD)
Entity type:Individual
Prefix:
First Name:TAEHAN
Middle Name:P
Last Name:KIM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:TAEHAN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:800 N WESTMORELAND RD STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1687
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1673
Practice Address - Country:US
Practice Address - Phone:847-535-7664
Practice Address - Fax:224-271-3150
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
IL036.169900207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program