MEDICARE: PROF. MOYUEN MIMI LEE MD

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	208600000X	Surgery Physician	E2338	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00037405	OTHER	AR	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	188290000000	OTHER	AR	QUALCHOICE
3	5L347	OTHER	AR	ARKANSAS BLUE CROSS AND BLUE SHIELD

General Provider Information

NPI Number	:	1720034358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. MOYUEN MIMI LEE MD

Provider Business Mailing Address
First Line	:	8315 CANTRELL RD
Second Line	:	PLAZA 80
City	:	LITTLE ROCK
State	:	AR
Zip	:	72227-2423
Country	:	US
Telephone Number	:	501-224-0880
Fax Number	:	501-224-1395

Provider Business Practice Location Address
First Line	:	8315 CANTRELL RD
Second Line	:	PLAZA 80
City	:	LITTLE ROCK
State	:	AR
Zip	:	72227-2423
Country	:	US
Telephone Number	:	501-224-0880
Fax Number	:	501-224-1395

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

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	10/22/2008

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