Healthcare Provider Details

I. General information

NPI: 1003800442
Provider Name (Legal Business Name): HANS LEE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 KANAWHA BLVD E SUITE 100
CHARLESTON WV
25301-3001
US

IV. Provider business mailing address

1306 KANAWHA BLVD E SUITE 100
CHARLESTON WV
25301-3001
US

V. Phone/Fax

Practice location:
  • Phone: 304-342-1113
  • Fax: 304-346-2271
Mailing address:
  • Phone: 304-342-1113
  • Fax: 304-346-2271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. THEODORE A JACKSON
Title or Position: PRESIDENT
Credential: M. D.
Phone: 304-342-1113