Provider Demographics
NPI:1174512867
Name:LEE, KENNETH ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
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 1:111 CYPRESS ST
Mailing Address - Street 2:BRIGHAM AND WOMENS PHYSICIANS ORGANIZATION
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445
Mailing Address - Country:US
Mailing Address - Phone:617-582-1200
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS STREET ARMORY 3
Practice Address - Street 2:BRIGHAM AND WOMENS HOSPITAL, DEPARTMENT OF PATHOLOGY
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-4715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79108207ZP0101X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3121208Medicaid
MA3121208Medicaid
MAD03244Medicare UPIN