Basic Information
| Provider Information | |||||||||
| NPI: | 1780823724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | DONOVAN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1367 ACORN DR | ||||||||
| Address2: | |||||||||
| City: | CREST HILL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604030952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157445524 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 S LAKE PARK AVE | ||||||||
| Address2: | |||||||||
| City: | HOBART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463426638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199420551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2009 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 336.085317 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 02004933A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201017380 | 05 | IN | MEDICAID |