=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780848978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN C. LEE, M.D., S.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2008
-----------------------------------------------------
Last Update Date | 07/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1714 S BLAINE LN
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-5025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-423-9000
-----------------------------------------------------
Fax | 217-423-9002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1714 S BLAINE LN
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62521-5025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-423-9000
-----------------------------------------------------
Fax | 217-423-9002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. JOHN C LEE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 217-423-9000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 036052344
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------