Provider Demographics
NPI:1710967435
Name:LEE, TAE AHN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:TAE AHN
Middle Name:THOMAS
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 1:658 W MARKET ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-4563
Mailing Address - Country:US
Mailing Address - Phone:419-227-5176
Mailing Address - Fax:
Practice Address - Street 1:658 W MARKET ST
Practice Address - Street 2:SUITE 200
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4563
Practice Address - Country:US
Practice Address - Phone:419-227-5176
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH351000362084P0800X, 2084P0805X
CAA337102084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
D31987Medicare UPIN
OHT9176401Medicare ID - Type Unspecified