MEDICARE: SHIN JI 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	174400000X	Specialist	191864-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	191864-1	OTHER	NY	LICENCE NUMBER

General Provider Information

NPI Number	:	1699003921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIN JI LEE M.D.

Provider Business Mailing Address
First Line	:	866 2ND AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10017-2905
Country	:	US
Telephone Number	:	516-280-8202
Fax Number	:	516-280-8204

Provider Business Practice Location Address
First Line	:	866 2ND AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10017-2905
Country	:	US
Telephone Number	:	516-280-8202
Fax Number	:	516-280-8204

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

Provider Enumeration Date	:	11/24/2009
Last Update Date	:	11/24/2009

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