Provider Demographics
NPI:1174588628
Name:LEE, THOMAS S (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:LEE
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 1:1890 SILVER CROSS BLVD
Mailing Address - Street 2:SUITE 370
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9524
Mailing Address - Country:US
Mailing Address - Phone:815-300-1450
Mailing Address - Fax:
Practice Address - Street 1:1890 SILVER CROSS BLVD
Practice Address - Street 2:SUITE 370
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-9524
Practice Address - Country:US
Practice Address - Phone:815-300-1450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093385Medicaid
ILL95606Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 16
ILL95607Medicare ID - Type UnspecifiedFEE SCHEDULE LOCALITY 15
G53043Medicare UPIN