Provider Demographics
NPI:1770511271
Name:LEE, KYEONG PHILIP (MD)
Entity type:Individual
Prefix:DR
First Name:KYEONG
Middle Name:PHILIP
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:621 S NEW BALLAS RD
Mailing Address - Street 2:SUITE 5003 B
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141
Mailing Address - Country:US
Mailing Address - Phone:314-227-2020
Mailing Address - Fax:317-227-2021
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:SUITE 5003 B
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141
Practice Address - Country:US
Practice Address - Phone:314-227-2020
Practice Address - Fax:314-227-2021
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2009-12-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO1055502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207678228Medicaid
MO207678228Medicaid
F88064Medicare UPIN