Basic Information
| Provider Information | |||||||||
| NPI: | 1760460091 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTENSEN | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 127TH ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604063802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7083880423 | ||||||||
| FaxNumber: | 7083881477 | ||||||||
| Practice Location | |||||||||
| Address1: | 12935 GREGORY ST | ||||||||
| Address2: | |||||||||
| City: | BLUE ISLAND | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604062428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085972000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 06/11/2010 | ||||||||
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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 | 2085R0202X | 036068104 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 036068104 | 05 | IL | MEDICAID | 01615363 | 01 | IL | BC GROUP PIN | OTHER |