Provider Demographics
NPI:1003800442
Name:HANS LEE, M. D., INC.
Entity Type:Organization
Organization Name:HANS LEE, M. D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:304-342-1113
Mailing Address - Street 1:1306 KANAWHA BLVD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3001
Mailing Address - Country:US
Mailing Address - Phone:304-342-1113
Mailing Address - Fax:304-346-2271
Practice Address - Street 1:1306 KANAWHA BLVD E
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3001
Practice Address - Country:US
Practice Address - Phone:304-342-1113
Practice Address - Fax:304-346-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0114231002Medicaid
WV0114231002Medicaid