Provider Demographics
NPI:1104034792
Name:LEE, SAEBOM (MD)
Entity Type:Individual
Prefix:
First Name:SAEBOM
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 GLENDALE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43614-2426
Mailing Address - Country:US
Mailing Address - Phone:419-383-3556
Mailing Address - Fax:419-383-3550
Practice Address - Street 1:3000 ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-2595
Practice Address - Country:US
Practice Address - Phone:419-383-3556
Practice Address - Fax:419-383-3550
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57010200207L00000X
OH35.093576207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP01077196OtherRR MEDICARE
OH2940803Medicaid
OHLE7401261Medicare PIN