MEDICARE: DR. KYU CHAN LEE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation	D0023629	MD

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	E10911	MEDICARE UPIN	MD
2	908R	MEDICARE ID-TYPE UNSPECIFIED	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205813144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KYU CHAN LEE M.D.

Provider Business Mailing Address
First Line	:	1600 CRAIN HWY S
Second Line	:	SUITE 402
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-5577
Country	:	US
Telephone Number	:	410-761-6500
Fax Number	:	410-761-1534

Provider Business Practice Location Address
First Line	:	1600 CRAIN HWY S.
Second Line	:	SUITE 402
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-6437
Country	:	US
Telephone Number	:	410-761-6500
Fax Number	:	410-761-1534

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2005
Last Update Date	:	03/08/2011

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Directions to “ DR. KYU CHAN LEE M.D.” Practice Location

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