Basic Information
| Provider Information | |||||||||
| NPI: | 1497818025 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | CHONG | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2847 | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973392847 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 155 KINGLSEY LANE SUITE 405 | ||||||||
| Address2: | BON SECOURS SURGICAL SPECIALISTS | ||||||||
| City: | NORFOLK | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7572782220 | ||||||||
| FaxNumber: | 7574890701 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 08/17/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD60920799 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | 4301064070 | MI | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | MD191833 | OR | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2155620 | 05 | WA | MEDICAID |