Basic Information
| Provider Information | |||||||||
| NPI: | 1225031925 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | DM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2102 E INWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466142443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742992400 | ||||||||
| FaxNumber: | 5742992410 | ||||||||
| Practice Location | |||||||||
| Address1: | 2102 E INWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466142443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742992400 | ||||||||
| FaxNumber: | 5742992410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 12/03/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01039479A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100143040 | 05 | IN | MEDICAID | 100114340A | 05 | IN | MEDICAID |