Provider Demographics
NPI:1437188018
Name:KIM, STANLEY (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-933-2489
Mailing Address - Fax:630-933-2827
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-933-2489
Practice Address - Fax:630-933-2827
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA717632085R0202X
IL0361098282085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A717630OtherMEDI CAL
IL036109828Medicaid
IL0222075OtherBLUE CROSS GROUP NUMBER
IL3631498336019001OtherCDPG HFS PAYEE ID
IL3625139096019701OtherCDH HFS GROUP PAYEE ID
CAWA71763BMedicare UPIN
CAWA71763AMedicare UPIN
IL3625139096019701OtherCDH HFS GROUP PAYEE ID
CAH89257Medicare UPIN