Healthcare Provider Details

I. General information

NPI: 1053313999
Provider Name (Legal Business Name): JAE HO LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 N MIDLAND AVE NYACK HOSPITAL
NYACK NY
10960-1912
US

IV. Provider business mailing address

43 KENSICO DR 2ND FLOOR
MOUNT KISCO NY
10549-1009
US

V. Phone/Fax

Practice location:
  • Phone: 914-666-8866
  • Fax:
Mailing address:
  • Phone: 914-666-8866
  • Fax: 914-666-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number205923
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01740743
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: