Basic Information
| Provider Information | |||||||||
| NPI: | 1669580478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JAE YOUNG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HAWKINS DRIVE | ||||||||
| Address2: | UNIVERSITY OF IOWA HOSPITALS AND CLINICS | ||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193563375 | ||||||||
| FaxNumber: | 3193562220 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWKINS DRIVE | ||||||||
| Address2: | UNIVERSITY OF IOWA HOSPITALS AND CLINICS | ||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 52242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193563375 | ||||||||
| FaxNumber: | 3193562220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 2085B0100X | SP181 | IA | X | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | SP181 | IA | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085U0001X | SP181 | IA | X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 0729459 | 05 | IA | MEDICAID | 20606 | 01 | IA | WELLMARK BCBS | OTHER |