Provider Demographics
NPI:1508434903
Name:FRUSON, LEE WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:WILLIAM
Last Name:FRUSON
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 1:1-1528 29TH AVENUE SW
Mailing Address - Street 2:
Mailing Address - City:CALGARY
Mailing Address - State:ALBERTA
Mailing Address - Zip Code:T2T IM3
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1161 W. HARRISON ST
Practice Address - Street 2:STE: 400
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:312-432-2300
Practice Address - Fax:708-409-5179
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-10-26
Deactivation Date:2021-09-13
Deactivation Code:
Reactivation Date:2021-10-26
Provider Licenses
StateLicense IDTaxonomies
IL036.158462207XS0114X
IL125.077332207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery