=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093874125
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TAY BONG LEE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 12/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 CENTRAL PARK SOUTH, SUITE 11B
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10019-1628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 212-759-9614
-----------------------------------------------------
Fax | 212-750-2849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38 DONNYBROOK DRIVE
-----------------------------------------------------
City | DEMAREST
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07627-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-767-7691
-----------------------------------------------------
Fax | 201-767-3672
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 115741
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 25MA02861600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------