1205047503 NPI number — ANDY LEE MD

Table of content: ANDY LEE MD (NPI 1205047503)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205047503 NPI number — ANDY LEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
ANDY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205047503
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
320 WHITTINGTON PKWY
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40222-4928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-625-5584
Provider Business Mailing Address Fax Number:
502-426-2264

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1850 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW ALBANY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47150-4990
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-625-5584
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/25/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  57010099 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 01066793A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 106117 . This is a "SIHO" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000622689 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 129703800 . This is a "US DEPT. OF LABOR" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 3722991000 . This is a "PASSPORT ADVANTAGE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100104020 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200948500 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 50024466 . This is a "PASSPORT" identifier . This identifiers is of the category "OTHER".




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