Basic Information
| Provider Information | |||||||||
| NPI: | 1023312584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JONATHAN M LEE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 PROVIDENCE HWY | ||||||||
| Address2: | SUITE 202-203 | ||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020261881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813261464 | ||||||||
| FaxNumber: | 7813269075 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 PROVIDENCE HWY | ||||||||
| Address2: | SUITE 202-203 | ||||||||
| City: | DEDHAM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 020261881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7813261464 | ||||||||
| FaxNumber: | 7813269075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2010 | ||||||||
| LastUpdateDate: | 04/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERNIST | ||||||||
| AuthorizedOfficialTelephone: | 7813261464 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 72678 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3062601 | 05 | MA | MEDICAID |