Healthcare Provider Details

I. General information

NPI: 1659805521
Provider Name (Legal Business Name): MALCOLM MANDELA LEE SR. MD, MPH, CLS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10735 S WESTERN AVE STE 6
CHICAGO IL
60643-3156
US

IV. Provider business mailing address

10735 S WESTERN AVE STE 6
CHICAGO IL
60643-3156
US

V. Phone/Fax

Practice location:
  • Phone: 888-499-7670
  • Fax: 708-967-0023
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744R1102X
TaxonomyResearch Study Specialist
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246Q00000X
TaxonomyPathology Specialist/Technologist
License Number
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: