Provider Demographics
NPI:1437124153
Name:LEE, GLENDA (MD)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8905 W LINCOLN AVE
Practice Address - Street 2:STE. 407
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2468
Practice Address - Country:US
Practice Address - Phone:414-545-8808
Practice Address - Fax:414-545-4920
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27018207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31434300Medicaid
WI32832400OtherGROUP MEDICAID
WI73116Medicare ID - Type Unspecified
WI31434300Medicaid