Active NPI
Jae K Kim, M.D.
- Anesthesiology Physician
- Canton, IL
National Provider Identifier
1316981491
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Anesthesiology Physician
- License
- 036056328
- Practice address
- 210 W Walnut St
Canton, IL 61520-2444 - Phone
- (309) 647-5240
- Fax
- (309) 647-5104
- NPI assigned
- Jun 16, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Anesthesiology Physician | 207L00000X | 036056328 | IL | Primary |
Addresses
Primary practice location
210 W Walnut St
Canton, IL 61520-2444
Mailing address
7309 N Knoxville Ave
Suite 200
Peoria, IL 61614-2085
Phone (309) 691-6225
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 036056328 | Medicaid | IL | |
| P00945642 | Other | IL | RAILROAD MEDICARE PTAN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: No
- Medical equipment: Yes
- Home health: No
- Power mobility devices: Yes
- Hospice: No
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Jae Kim, M.D. | Anesthesiology | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Anesthesiology Physician
- Canton, IL
- NPI 1710928627
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1150416000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1430697600000",
"number": "1316981491",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7309 N KNOXVILLE AVE",
"address_2": "SUITE 200",
"city": "PEORIA",
"state": "IL",
"postal_code": "616142085",
"telephone_number": "309-691-6225",
"fax_number": "309-691-7635"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "210 W WALNUT ST",
"city": "CANTON",
"state": "IL",
"postal_code": "615202444",
"telephone_number": "309-647-5240",
"fax_number": "309-647-5104"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KIM",
"first_name": "JAE",
"middle_name": "K",
"credential": "M.D.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-06-16",
"last_updated": "2015-05-04",
"status": "A"
},
"taxonomies": [
{
"code": "207L00000X",
"taxonomy_group": "",
"desc": "Anesthesiology",
"state": "IL",
"license": "036056328",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "036056328",
"state": "IL"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "RAILROAD MEDICARE PTAN",
"identifier": "P00945642",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Canton, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 4, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.