=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003259284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIMI C LEE, MD PHD, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2013
-----------------------------------------------------
Last Update Date | 01/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 ALICE B TOKLAS PL UNIT 708
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94109-6962
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-846-9989
-----------------------------------------------------
Fax | 704-973-0815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 ALICE B. TOKLAS PLACE
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-846-9989
-----------------------------------------------------
Fax | 704-973-0815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MIMI C. LEE
-----------------------------------------------------
Credential | MDPHD
-----------------------------------------------------
Telephone | 415-846-9989
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | A76994
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------