Basic Information
| Provider Information | |||||||||
| NPI: | 1326037383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JONG-IL | ||||||||
| MiddleName: | MARCUS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 E 86TH AVE | ||||||||
| Address2: | PO BOX 10645 | ||||||||
| City: | MERRILLVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 464106382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2197691670 | ||||||||
| FaxNumber: | 2197386714 | ||||||||
| Practice Location | |||||||||
| Address1: | 5454 HOHMAN AVE | ||||||||
| Address2: | |||||||||
| City: | HAMMOND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463201931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199332006 | ||||||||
| FaxNumber: | 2197386714 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 01/25/2012 | ||||||||
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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 | 2085N0904X | 01031807 | IN | N | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 01031807 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100361350 | 05 | IN | MEDICAID |