Basic Information
| Provider Information | |||||||||
| NPI: | 1376560854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3530 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148646039 | ||||||||
| FaxNumber: | 8148646760 | ||||||||
| Practice Location | |||||||||
| Address1: | 3530 PEACH ST | ||||||||
| Address2: | |||||||||
| City: | ERIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 165082768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8148646039 | ||||||||
| FaxNumber: | 8148646760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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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 | 207Q00000X | MD438414 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | MD438414 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.