Provider Demographics
NPI:1043373517
Name:MARY A LEE MD INC
Entity Type:Organization
Organization Name:MARY A LEE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:513-722-2603
Mailing Address - Street 1:6746 DICK FLYNN BLVD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:OH
Mailing Address - Zip Code:45122-8609
Mailing Address - Country:US
Mailing Address - Phone:513-722-2603
Mailing Address - Fax:513-722-3423
Practice Address - Street 1:6746 DICK FLYNN BLVD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:OH
Practice Address - Zip Code:45122-8609
Practice Address - Country:US
Practice Address - Phone:513-722-2603
Practice Address - Fax:513-722-3423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041350207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0344041Medicaid
OHP00608181OtherMEDICARE RR
OH0438164Medicare PIN