Provider Demographics
NPI:1023312584
Name:JONATHAN M LEE LLC
Entity type:Organization
Organization Name:JONATHAN M LEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:781-326-1464
Mailing Address - Street 1:200 PROVIDENCE HWY
Mailing Address - Street 2:SUITE 202-203
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-1881
Mailing Address - Country:US
Mailing Address - Phone:781-326-1464
Mailing Address - Fax:781-326-9075
Practice Address - Street 1:200 PROVIDENCE HWY
Practice Address - Street 2:SUITE 202-203
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-1881
Practice Address - Country:US
Practice Address - Phone:781-326-1464
Practice Address - Fax:781-326-9075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72678207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3062601Medicaid
MAE56642Medicare UPIN
MA3062601Medicaid