Provider Demographics
NPI:1659365013
Name:HANS LEE MD INC
Entity Type:Organization
Organization Name:HANS LEE MD INC
Other - Org Name:LEES SURGICENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-342-1113
Mailing Address - Street 1:1306 KANAWHA BLVD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-3001
Mailing Address - Country:US
Mailing Address - Phone:304-342-1113
Mailing Address - Fax:304-346-2271
Practice Address - Street 1:1306 KANAWHA BLVD E
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-3001
Practice Address - Country:US
Practice Address - Phone:304-342-1113
Practice Address - Fax:304-346-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0114231001Medicaid
5110091Medicare PIN