Provider Demographics
NPI:1407876519
Name:LEE, THOMAS GREGORY (DO)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:GREGORY
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2850
Mailing Address - Country:US
Mailing Address - Phone:309-691-1259
Mailing Address - Fax:309-683-8911
Practice Address - Street 1:6915 N KNOXVILLE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2850
Practice Address - Country:US
Practice Address - Phone:309-691-1259
Practice Address - Fax:309-683-8911
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-087310207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL0101OtherJOHN DEERE PROVIDER ID#
IL036087310Medicaid
IL023867OtherHEALTH ALLIANCE PROVIDER
IL0007223615OtherBCBS PROVIDER ID#
IL291798OtherHEALTHLINK PROVIDER ID#
IL0007223615OtherBCBS PROVIDER ID#