Provider Demographics
NPI:1346400744
Name:LEE SELF MD PA
Entity Type:Organization
Organization Name:LEE SELF MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-425-7507
Mailing Address - Street 1:23000 SWEET OLA HWY
Mailing Address - Street 2:
Mailing Address - City:OLA
Mailing Address - State:ID
Mailing Address - Zip Code:83657-5027
Mailing Address - Country:US
Mailing Address - Phone:208-425-7507
Mailing Address - Fax:208-584-9341
Practice Address - Street 1:2020 S JOHNS AVE STE B
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9410
Practice Address - Country:US
Practice Address - Phone:208-425-7507
Practice Address - Fax:208-584-9341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7844174400000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1375817Medicare PIN