Provider Demographics
NPI:1073551644
Name:LEE JENKINS MD SC
Entity Type:Organization
Organization Name:LEE JENKINS MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-450-4950
Mailing Address - Street 1:675 W NORTH AVE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160
Mailing Address - Country:US
Mailing Address - Phone:708-450-4950
Mailing Address - Fax:708-343-8505
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160
Practice Address - Country:US
Practice Address - Phone:708-450-4950
Practice Address - Fax:708-343-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2008-09-08
Deactivation Date:2008-08-25
Deactivation Code:
Reactivation Date:2008-09-04
Provider Licenses
StateLicense IDTaxonomies
208600000X
IL036088632208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088632Medicaid
IL1623294OtherBLUE CROSS / BLUE SHIELD
IL036088632Medicaid
IL036088632Medicaid