1275683211 NPI number — SOO MI LEE - SAMUEL MD

Table of content: SOO MI LEE - SAMUEL MD (NPI 1275683211)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275683211 NPI number — SOO MI LEE - SAMUEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE - SAMUEL
Provider First Name:
SOO
Provider Middle Name:
MI
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
SOO
Provider Other Middle Name:
MI
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275683211
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 E. WOODFIELD ROAD
Provider Second Line Business Mailing Address:
SUITE 1000
Provider Business Mailing Address City Name:
SCHAUMBURG
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60173-5113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-240-2211
Provider Business Mailing Address Fax Number:
847-240-2418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 E CONGRESS PKWY
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-6202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-356-5050
Provider Business Practice Location Address Fax Number:
815-356-5094
Provider Enumeration Date:
01/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0804X , with the licence number:  036-109024 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1633897 . This is a "GROUP BCBS NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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