Basic Information
| Provider Information | |||||||||
| NPI: | 1376564393 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAX M. LEE, M.D. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MAX LEE, M.D. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 19711 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | NORMANDY PARK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981482401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065925000 | ||||||||
| FaxNumber: | 2068249510 | ||||||||
| Practice Location | |||||||||
| Address1: | 19711 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | NORMANDY PARK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981482401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068242183 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 04/06/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | MAX | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2068242183 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1592708 | 05 | WA | MEDICAID | 760111256 | 01 | WA | RR MEDICARE | OTHER |