Basic Information
| Provider Information | |||||||||
| NPI: | 1508434903 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRUSON | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1-1528 29TH AVENUE SW | ||||||||
| Address2: | |||||||||
| City: | CALGARY | ||||||||
| State: | ALBERTA | ||||||||
| PostalCode: | T2T IM3 | ||||||||
| CountryCode: | CA | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1161 W. HARRISON ST | ||||||||
| Address2: | STE: 400 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3124322300 | ||||||||
| FaxNumber: | 7084095179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/13/2021 | ||||||||
| NPIReactivationDate: | 10/26/2021 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0114X | 036.158462 | IL | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0114X | 125.077332 | IL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery |
No ID Information.