Provider Demographics
NPI:1518006071
Name:LEE, KIL SOO (MD)
Entity Type:Individual
Prefix:MR
First Name:KIL SOO
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 1:55 WESTPORT PLZ
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3109
Mailing Address - Country:US
Mailing Address - Phone:314-548-4772
Mailing Address - Fax:314-548-4748
Practice Address - Street 1:11133 DUNN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6119
Practice Address - Country:US
Practice Address - Phone:314-653-4300
Practice Address - Fax:314-821-5600
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO036-0601742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200610103Medicaid
MO013012444Medicare PIN
MOA27743Medicare UPIN
ILL40193Medicare PIN