Healthcare Provider Details

I. General information

NPI: 1609852177
Provider Name (Legal Business Name): SUSANNE NUSSEN LEE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 08/17/2022
Certification Date: 08/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 W CHESTER PIKE BLDG D SUITE 120
NEWTOWN SQUARE PA
19073-2329
US

IV. Provider business mailing address

14275 MIDWAY RD STE 400
ADDISON TX
75001-3614
US

V. Phone/Fax

Practice location:
  • Phone: 800-257-0117
  • Fax: 610-550-3079
Mailing address:
  • Phone:
  • Fax: 610-271-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberC1-0008614
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD421782
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberMD421782
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: