Basic Information
Provider Information | |||||||||
NPI: | 1528059664 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | HO | ||||||||
MiddleName: | KYU | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEE | ||||||||
OtherFirstName: | HOKYU | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1420 STEPHENSON HWY | ||||||||
Address2: |   | ||||||||
City: | TROY | ||||||||
State: | MI | ||||||||
PostalCode: | 480831189 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3137453430 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4201 SAINT ANTOINE ST | ||||||||
Address2: | DRH 3L-8 | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012153 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3137453430 | ||||||||
FaxNumber: | 3135778600 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/28/2005 | ||||||||
LastUpdateDate: | 05/04/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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 | 2085N0700X | SP-158 | IA | N |   | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 4301091185 | MI | Y |   | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 0439190 | 05 | IA |   | MEDICAID | 36327 | 01 | IA | WELLMARK BCBS | OTHER |