Basic Information
| Provider Information | |||||||||
| NPI: | 1134176126 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | ANDY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | W-LL300 | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184450220 | ||||||||
| FaxNumber: | 7189391167 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | W-LL300 | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184450220 | ||||||||
| FaxNumber: | 7189391167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 11/05/2010 | ||||||||
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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 | 208600000X | 195169 | NY | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 195169 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 020053884 | 01 | NY | RAILROAD MEDICARE-CRT | OTHER | 02171566 | 05 | NY | MEDICAID |