Basic Information
| Provider Information | |||||||||
| NPI: | 1942236674 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAI KWONG LEE,MD,PHD, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7001 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913577001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188887815 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Practice Location | |||||||||
| Address1: | 15107 VANOWEN ST | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914054542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187826600 | ||||||||
| FaxNumber: | 8187151722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 09/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | LEE | ||||||||
| AuthorizedOfficialFirstName: | TAI | ||||||||
| AuthorizedOfficialMiddleName: | KWONG | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8188887815 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | A69722 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | A69722 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A697221 | 01 | CA | BLUE SHIELD | OTHER | WA69722A | 01 | CA | MEDICARE PPIN | OTHER |