Provider Demographics
NPI:1952369563
Name:TERMOLEN, SHIRLEY LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:LEE
Last Name:TERMOLEN
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 1:200 S MICHIGAN AVE
Mailing Address - Street 2:SUITE 805
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-2402
Mailing Address - Country:US
Mailing Address - Phone:312-922-3815
Mailing Address - Fax:312-922-7449
Practice Address - Street 1:200 S MICHIGAN AVE
Practice Address - Street 2:SUITE 805
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-2402
Practice Address - Country:US
Practice Address - Phone:312-922-3815
Practice Address - Fax:312-922-7449
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096045207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360960451Medicaid
IL363762672OtherTAX ID FOR PRACTICE
IL363762672OtherTAX ID FOR PRACTICE
ILG80433Medicare UPIN