Basic Information
| Provider Information | |||||||||
| NPI: | 1366870180 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHEAL T LEE MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 E HIGHLAND AVE | ||||||||
| Address2: | SUITE 425 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026676640 | ||||||||
| FaxNumber: | 6026673305 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 E HIGHLAND AVE | ||||||||
| Address2: | SUITE 425 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026676640 | ||||||||
| FaxNumber: | 6026673305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2013 | ||||||||
| LastUpdateDate: | 10/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 6026676640 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 22408 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1758293 | 05 | AZ | MEDICAID | 4193000 | 01 | AZ | CIGNA | OTHER | AZ0830720 | 01 | AZ | BLUE CROSS BLUE SHIELD | OTHER | POR13LEE9MI1 | 05 | AZ | MEDICAID |