Basic Information
| Provider Information | |||||||||
| NPI: | 1093786733 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 GUTHRIE SQ | ||||||||
| Address2: | |||||||||
| City: | SAYRE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 188401625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5708885858 | ||||||||
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| Practice Location | |||||||||
| Address1: | 176 DENISON PKWY E | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148302814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6079377278 | ||||||||
| FaxNumber: | 6079377860 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 09/14/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 113108-1 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0018676990002 | 05 | PA | MEDICAID | 00373139 | 05 | NY | MEDICAID | CC8362 | 01 | NY | RR MEDICARE GROUP | OTHER | 050083222 | 01 | NY | RR MEDICARE PIN | OTHER |