Provider Demographics
NPI:1104826973
Name:LEE, JAE YOUNG (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:YOUNG
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 1:130 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARINE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48039-1680
Mailing Address - Country:US
Mailing Address - Phone:810-765-8844
Mailing Address - Fax:810-765-4326
Practice Address - Street 1:130 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARINE CITY
Practice Address - State:MI
Practice Address - Zip Code:48039-1680
Practice Address - Country:US
Practice Address - Phone:810-765-8844
Practice Address - Fax:810-765-4326
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2011-01-14
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
MI4301033400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1068960Medicaid
MI1068960Medicaid
MI3740520Medicare ID - Type Unspecified