Provider Demographics
NPI:1043245970
Name:LEE, KENNETH K (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:K
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 1:885 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6141
Mailing Address - Country:US
Mailing Address - Phone:630-545-3760
Mailing Address - Fax:630-545-3769
Practice Address - Street 1:885 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6141
Practice Address - Country:US
Practice Address - Phone:630-545-3760
Practice Address - Fax:630-545-3769
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0222075OtherBLUE CROSS GROUP NUMBER
IL3631498336019001OtherCDPG HFS PAYEE ID
IL363149833OtherTAX IDENTIFICATION NUMBER
IL036100509Medicaid
IL920780Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
IL487450Medicare PIN
IL036100509Medicaid
IL363149833OtherTAX IDENTIFICATION NUMBER