Basic Information
| Provider Information | |||||||||
| NPI: | 1982628475 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 WARRENVILLE RD | ||||||||
| Address2: | SUITE 280 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303247900 | ||||||||
| FaxNumber: | 6303247942 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE INGALLS DRIVE | ||||||||
| Address2: | WEST 536 | ||||||||
| City: | HARVEY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7089156870 | ||||||||
| FaxNumber: | 7083339105 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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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 | 208G00000X | 036079191 | IL | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 36079191 | 05 | IL | MEDICAID |