Basic Information
| Provider Information | |||||||||
| NPI: | 1639170186 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | SOONG | ||||||||
| MiddleName: | GONG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 200068 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152510068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882761003 | ||||||||
| FaxNumber: | 7173902455 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 BERNVILLE RD | ||||||||
| Address2: | |||||||||
| City: | READING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 196059453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103730165 | ||||||||
| FaxNumber: | 6103735251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 08/01/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD022252E | PA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 100544 | 01 | BS | OTHER | 0009370190004 | 05 | PA | MEDICAID | 01543501 | 01 | BC | OTHER |