Healthcare Provider Details

I. General information

NPI: 1952304933
Provider Name (Legal Business Name): YONG S. LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 BILL CARRUTH PKWY STE 120
HIRAM GA
30141-3756
US

IV. Provider business mailing address

900 CIRCLE 75 PKWY SE SUITE 1700
ATLANTA GA
30339-3035
US

V. Phone/Fax

Practice location:
  • Phone: 770-445-5666
  • Fax:
Mailing address:
  • Phone: 770-953-6929
  • Fax: 770-953-6972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number37597
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number37597
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number37597
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: