Basic Information
| Provider Information | |||||||||
| NPI: | 1134118482 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | #5006B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144325478 | ||||||||
| FaxNumber: | 3145690864 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | #5006B | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144325478 | ||||||||
| FaxNumber: | 3145690864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 02/04/2011 | ||||||||
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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 | 207W00000X | 108687 | MO | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 036099328 | IL | N | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 21577 | 01 | MO | BCBS | OTHER | 273460 | 01 | MO | HEALTHLINK | OTHER | 208033910 | 05 | MO | MEDICAID | K12557 | 01 | IL | MEDICARE ILLINOIS | OTHER | 1134118482 | 05 | MO | MEDICAID |