Provider Demographics
NPI:1356500086
Name:ROBERT J. LEE, M.D., PC
Entity Type:Organization
Organization Name:ROBERT J. LEE, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:JENSEN
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-522-4409
Mailing Address - Street 1:PO BOX 1583
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-1583
Mailing Address - Country:US
Mailing Address - Phone:208-522-4409
Mailing Address - Fax:208-522-4497
Practice Address - Street 1:3446 S 15TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8262
Practice Address - Country:US
Practice Address - Phone:208-522-4409
Practice Address - Fax:208-522-4497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2010-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7277207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1356500086OtherGROUP NPI
ID1710985551OtherINDIVIDUAL NPI
ID135650086002Medicaid
ID1710985551001Medicaid
ID135650086001Medicaid
ID1137476Medicare PIN
ID1374111Medicare PIN
ID1710985551OtherINDIVIDUAL NPI
ID5670790001Medicare NSC