1821301268 NPI number — CHAN LEE M.D.

Table of content: CHAN LEE M.D. (NPI 1821301268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821301268 NPI number — CHAN LEE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
CHAN
Provider Middle Name:
Provider Name Prefix Text:
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:
1821301268
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5545
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47903-5545
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-448-8000
Provider Business Mailing Address Fax Number:
765-838-5150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 GREENBUSH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47904-2477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-448-8000
Provider Business Practice Location Address Fax Number:
765-838-5150
Provider Enumeration Date:
07/14/2010

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: 207R00000X , with the licence number:  2010017740 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 11016800 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 01075343A , 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: 201107640 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000943929 . This is a "ANTHEM PROVIDER NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 01075343A . This is a "MEDICAL LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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