Provider Demographics
NPI:1518143478
Name:LEE, MAXIMILIAN (MD)
Entity Type:Individual
Prefix:
First Name:MAXIMILIAN
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:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:747 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4379
Practice Address - Country:US
Practice Address - Phone:206-386-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60222397207RG0100X
CAA92442207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8902201Medicare PIN
WA1518143478OtherMONTANA DSHS
WA89084455Medicare PIN
CACA104665Medicare PIN
WA1518143478Medicaid
WAP01004338OtherRAILROAD MEDICARE
WA8902200Medicare PIN