MEDICARE: MARK EUNGSANG LEE PT

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	225100000X	Physical Therapist	40QA01075900	NJ

General Provider Information

NPI Number	:	1831371566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK EUNGSANG LEE PT

Provider Business Mailing Address
First Line	:	1608 LEMOINE AVE
Second Line	:	STE 202
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5636
Country	:	US
Telephone Number	:	201-894-5451
Fax Number	:	201-334-0068

Provider Business Practice Location Address
First Line	:	1608 LEMOINE AVE STE 202
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-5636
Country	:	US
Telephone Number	:	18-945-4512
Fax Number	:	201-334-0068

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

Provider Enumeration Date	:	12/05/2007
Last Update Date	:	01/06/2022

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