Basic Information
Provider Information
NPI: 1003805243
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEE
FirstName: SANGHEE
MiddleName: ROSE
NamePrefix: DR.
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1316 W ONTARIO ST
Address2: 9TH FLOOR
City: PHILADELPHIA
State: PA
PostalCode: 191405220
CountryCode: US
TelephoneNumber: 2157079403
FaxNumber: 2152251698
Practice Location
Address1: 3401 N BROAD ST
Address2:  
City: PHILADELPHIA
State: PA
PostalCode: 191405103
CountryCode: US
TelephoneNumber: 8008367536
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/20/2005
LastUpdateDate: 10/23/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000XOS014484PAN Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000X236291NYN Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000X0102202577VAY Allopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
209317901PAHIGHMARK BLUE SHIELDOTHER
102263101000205PA MEDICAID
182104861201NYGROUP NPI NUMBEROTHER
102263101000105PA MEDICAID
100380524301NYNPI NUMBEROTHER


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