Provider Demographics
NPI:1508861337
Name:KONECKE, LEE (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:KONECKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:207 N. BROAD STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:215-462-7100
Mailing Address - Fax:215-463-3820
Practice Address - Street 1:676 DEKALB PIKE
Practice Address - Street 2:STE 101
Practice Address - City:BLUE BELL
Practice Address - State:PA
Practice Address - Zip Code:19422-1223
Practice Address - Country:US
Practice Address - Phone:610-279-7696
Practice Address - Fax:610-279-7782
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD010173E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006943220017Medicaid
PA163703GT6Medicare PIN