=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073551644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEE JENKINS MD SC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 09/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 W NORTH AVE SUITE 408
-----------------------------------------------------
City | MELROSE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-450-4950
-----------------------------------------------------
Fax | 708-343-8505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 675 W NORTH AVE SUITE 408
-----------------------------------------------------
City | MELROSE PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-450-4950
-----------------------------------------------------
Fax | 708-343-8505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD PRESIDENT
-----------------------------------------------------
Name | DR. LEE THOMAS JENKINS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 708-450-4950
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 036088632
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------