Provider Demographics
NPI:1669463618
Name:LEE, KEW-JUNG (MD)
Entity Type:Individual
Prefix:
First Name:KEW-JUNG
Middle Name:
Last Name:LEE
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 1:830 W DIVERSEY PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1454
Mailing Address - Country:US
Mailing Address - Phone:773-281-3563
Mailing Address - Fax:773-880-6051
Practice Address - Street 1:830 W DIVERSEY PKWY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1454
Practice Address - Country:US
Practice Address - Phone:773-281-3563
Practice Address - Fax:773-880-6051
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-091450207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091450Medicaid
ILG36503Medicare UPIN
ILL90191Medicare PIN