Basic Information
| Provider Information | |||||||||
| NPI: | 1538239819 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MIKYUNG | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 E 42ND ST FL 9 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100175699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466058186 | ||||||||
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| Practice Location | |||||||||
| Address1: | 17 E 102ND ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100295204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122417968 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 05/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 229632 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 229632 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 1423323 | 01 | AETNA HMO | OTHER | 396943 | 01 | MVP HEALTHPLAN | OTHER | 450AP1 | 01 | EMPIRE BC-BS | OTHER | P003676971 | 01 | RAILROAD MEDICARE PIN# | OTHER | 000000114410 | 01 | GHI - HMO | OTHER | 7988846 | 01 | AETNA PROVIDER ID PPO | OTHER | 07020900104 | 01 | FIDELIS CARE OF NY | OTHER | NWH TAX ID | 01 | DEVON HEALTH GRP PIN# | OTHER | 0140665 | 01 | GHI PPO PROVIDER ID | OTHER | 10119993-U104 | 01 | CDPHP PROVIDER # &GRP # | OTHER | NWH TAX ID | 01 | PHCS-PROVIDER ID | OTHER | 31967773 | 01 | CIGNA HEALTH CARE | OTHER | NWH TAX ID | 01 | CHN SOLUTIONS -GRP PIN # | OTHER | NWH TAX ID | 01 | BEECH STREET PROVIDER ID | OTHER | NWH TAX ID | 01 | POMCO PROVIDER # | OTHER |