Provider Demographics
NPI:1780848978
Name:JOHN C. LEE, M.D., S.C.
Entity type:Organization
Organization Name:JOHN C. LEE, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:217-423-9000
Mailing Address - Street 1:1714 S BLAINE LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5025
Mailing Address - Country:US
Mailing Address - Phone:217-423-9000
Mailing Address - Fax:217-423-9002
Practice Address - Street 1:1714 S BLAINE LN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5025
Practice Address - Country:US
Practice Address - Phone:217-423-9000
Practice Address - Fax:217-423-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036052344207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0005800230OtherBCBS
IL036052344Medicaid
IL237480Medicare PIN
IL036052344Medicaid
IL0005800230OtherBCBS