Basic Information
| Provider Information | |||||||||
| NPI: | 1992872634 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUK S LEE M.D. INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 701 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604380701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193227042 | ||||||||
| FaxNumber: | 2193224155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E 9TH ST | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469758931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742241156 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | SUK | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2193227042 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0904X | 1030530 | IN | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | 01030530 | IN | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085N0904X | IL | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Nuclear Radiology | 2085R0202X | IL | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 5830160036 | 05 | IL | MEDICAID |