Provider Demographics
NPI:1013121094
Name:LEE, SOONG HYUN (MD)
Entity Type:Individual
Prefix:
First Name:SOONG
Middle Name:HYUN
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 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-358-2700
Mailing Address - Fax:704-358-2716
Practice Address - Street 1:BEHAVIORAL HEALTH CENTER CMC RANDOLPH
Practice Address - Street 2:501 BILLINGSLEY ROAD
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1009
Practice Address - Country:US
Practice Address - Phone:704-358-2700
Practice Address - Fax:704-358-2716
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC176872084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNC1014Medicaid
NC1013121094Medicaid
NC891174NMedicaid
SCNC1014Medicaid
NC1013121094Medicaid
NCNC4315AMedicare PIN