Basic Information
| Provider Information | |||||||||
| NPI: | 1023308202 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | BOEUN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 MCCLINTOCK DR | ||||||||
| Address2: | STE 202 | ||||||||
| City: | BURR RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605270872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Practice Location | |||||||||
| Address1: | 2923 N CALIFORNIA AVE | ||||||||
| Address2: | STE 220 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606187702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882206432 | ||||||||
| FaxNumber: | 6307344715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2011 | ||||||||
| LastUpdateDate: | 07/18/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | 036131221 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 036131221 | 05 | IL | MEDICAID |