Provider Demographics
NPI:1710947080
Name:LEE, ALBERT ILSUN (MD)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:ILSUN
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 1:1499 FAIR RD
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-1683
Mailing Address - Country:US
Mailing Address - Phone:912-486-1482
Mailing Address - Fax:
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:SUITE 206
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0822
Practice Address - Country:US
Practice Address - Phone:912-871-5951
Practice Address - Fax:912-871-2483
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2016-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041454207L00000X
SC26846207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G98393Medicare UPIN
SC268463Medicaid