Healthcare Provider Details

I. General information

NPI: 1275683211
Provider Name (Legal Business Name): SOO MI LEE - SAMUEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SOO MI LEE MD

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 E CONGRESS PKWY SUITE J
CRYSTAL LAKE IL
60014-6202
US

IV. Provider business mailing address

1701 E. WOODFIELD ROAD SUITE 1000
SCHAUMBURG IL
60173-5113
US

V. Phone/Fax

Practice location:
  • Phone: 815-356-5050
  • Fax: 815-356-5094
Mailing address:
  • Phone: 847-240-2211
  • Fax: 847-240-2418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036-109024
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1633897
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerGROUP BCBS NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: