1629075684 NPI number — DR. STEVEN BRENT LEE M.D.

Table of content: DR. STEVEN BRENT LEE M.D. (NPI 1629075684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629075684 NPI number — DR. STEVEN BRENT LEE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
STEVEN
Provider Middle Name:
BRENT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1629075684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25488
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALT LAKE CITY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84125-0488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-475-3698
Provider Business Mailing Address Fax Number:
801-296-6199

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1433 N 1075 W STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARMINGTON
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84025-2746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-298-1300
Provider Business Practice Location Address Fax Number:
801-296-6199
Provider Enumeration Date:
07/06/2005

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: 2085R0202X , with the licence number:  344326-1205 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100505537 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00199633 . This is a "RR MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: P00651543 . This is a "RR MEDICARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 805962400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120740700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 923608 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: D3747 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




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