Provider Demographics
NPI:1225108855
Name:LEE, SHAOTSENG
Entity Type:Individual
Prefix:
First Name:SHAOTSENG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3089
Mailing Address - Country:US
Mailing Address - Phone:309-655-7801
Mailing Address - Fax:309-655-7812
Practice Address - Street 1:200 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3089
Practice Address - Country:US
Practice Address - Phone:309-655-7801
Practice Address - Fax:309-655-7812
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G37596Medicare UPIN
ILL58433Medicare ID - Type UnspecifiedINDIVIDUAL #
IL080092669 - CA4079Medicare ID - Type UnspecifiedRR
IL837660Medicare ID - Type UnspecifiedGROUP #