Provider Demographics
NPI:1861553240
Name:LEE, ANITA C (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:C
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:T
Other - Last Name:CHENG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:15 STONEY CT
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-2743
Mailing Address - Country:US
Mailing Address - Phone:309-662-5066
Mailing Address - Fax:309-662-5066
Practice Address - Street 1:2427 MALONEY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3750
Practice Address - Country:US
Practice Address - Phone:309-663-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-101027208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-101027Medicaid