Basic Information
| Provider Information | |||||||||
| NPI: | 1740243989 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | ELBERT | ||||||||
| MiddleName: | C. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172584042 | ||||||||
| FaxNumber: | 2172584053 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 HEALTH CENTER DRIVE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172584042 | ||||||||
| FaxNumber: | 2172584053 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2006 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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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 | 2084P0800X | 036096877 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | CH4443 | 01 | IL | RR GROUP NUMBER | OTHER | 036096877 | 05 | IL | MEDICAID | 260045697 | 01 | IL | RRR MEDICARE NUMBER | OTHER |