Basic Information
| Provider Information | |||||||||
| NPI: | 1972586147 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MYRON | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5050 SKYLINE VILLAGE LOOP S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973069490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033911110 | ||||||||
| FaxNumber: | 5033704237 | ||||||||
| Practice Location | |||||||||
| Address1: | 5050 SKYLINE VILLAGE LOOP S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973069490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033911110 | ||||||||
| FaxNumber: | 5033704237 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 01/17/2012 | ||||||||
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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 | 207Q00000X | MD13766 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 192351 | 05 | OR | MEDICAID |