Healthcare Provider Details

I. General information

NPI: 1588624829
Provider Name (Legal Business Name): NAM SOO LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1726 CAMPBELL AVE
SCHENECTADY NY
12306
US

IV. Provider business mailing address

1726 CAMPBELL AVE
SCHENECTADY NY
12306
US

V. Phone/Fax

Practice location:
  • Phone: 518-372-6557
  • Fax: 518-372-3472
Mailing address:
  • Phone: 518-372-6557
  • Fax: 518-372-3472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number133102
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier0404260006727
Identifier TypeOTHER
Identifier State
Identifier IssuerFIDELIS
# 2
Identifier10002697
Identifier TypeOTHER
Identifier State
Identifier IssuerCDPHP
# 3
Identifier26103
Identifier TypeOTHER
Identifier State
Identifier IssuerMVP
# 4
Identifier76E58
Identifier TypeOTHER
Identifier State
Identifier IssuerEMPIRE BC
# 5
Identifier000401636001
Identifier TypeOTHER
Identifier State
Identifier IssuerBLUE SHIELD
# 6
Identifier00561477
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: