Provider Demographics
NPI:1285744060
Name:LEE, BRIAN R
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 N 27TH STREET
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864
Mailing Address - Country:US
Mailing Address - Phone:618-244-3668
Mailing Address - Fax:618-244-0534
Practice Address - Street 1:221 N 27TH STREET
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864
Practice Address - Country:US
Practice Address - Phone:618-244-3668
Practice Address - Fax:618-244-0534
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003846213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0060201277OtherBLUE CROSS/BLUE SHIELD
IL480011933OtherRAILROAD MEDICARE
IL016003846Medicaid
IL016003846Medicaid
IL760751Medicare ID - Type Unspecified
T38663Medicare UPIN