Basic Information
| Provider Information | |||||||||
| NPI: | 1194723163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROWE | ||||||||
| FirstName: | LEE | ||||||||
| MiddleName: | DICKINSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2450 W HUNTING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191291302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159269022 | ||||||||
| FaxNumber: | 2152268286 | ||||||||
| Practice Location | |||||||||
| Address1: | 2340 E ALLEGHENY AVE | ||||||||
| Address2: | |||||||||
| City: | PHILA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191344433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154236670 | ||||||||
| FaxNumber: | 2154237787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 12/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/16/2006 | ||||||||
| NPIReactivationDate: | 03/29/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0007X | MD017012E | PA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 000813272 | 05 | PA | MEDICAID |