MEDICARE: DR. JUNG HUN LEE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0000X	Cardiovascular Disease Physician	R8562	MO

General Provider Information

NPI Number	:	1396743928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JUNG HUN LEE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 309
Second Line	:
City	:	CRYSTAL CITY
State	:	MO
Zip	:	63019-0309
Country	:	US
Telephone Number	:	636-937-0817
Fax Number	:	636-937-8818

Provider Business Practice Location Address
First Line	:	170 INDUSTRIAL DR.
Second Line	:	MEDICAL VILLAGE BLDG, SUITE 105
City	:	CRYSTAL CITY
State	:	MO
Zip	:	63019
Country	:	US
Telephone Number	:	636-937-0817
Fax Number	:	636-937-8818

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	04/15/2008

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