Provider Demographics
NPI:1275683211
Name:LEE - SAMUEL, SOO MI (MD)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:MI
Last Name:LEE - SAMUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SOO
Other - Middle Name:MI
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1701 E. WOODFIELD ROAD
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-5113
Mailing Address - Country:US
Mailing Address - Phone:847-240-2211
Mailing Address - Fax:847-240-2418
Practice Address - Street 1:390 E CONGRESS PKWY
Practice Address - Street 2:SUITE J
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6202
Practice Address - Country:US
Practice Address - Phone:815-356-5050
Practice Address - Fax:815-356-5094
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-1090242084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1633897OtherGROUP BCBS NUMBER
IL32-0084889OtherGROUP TAX ID NUMBER
IL32-0084889OtherGROUP TAX ID NUMBER