Provider Demographics
NPI:1255310363
Name:LEE, CHARLES IVY (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:IVY
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 1:717 PRATT AVE NE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-3645
Mailing Address - Country:US
Mailing Address - Phone:256-808-2273
Mailing Address - Fax:
Practice Address - Street 1:717 PRATT AVE NE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3645
Practice Address - Country:US
Practice Address - Phone:256-808-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2018-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00014864207L00000X
AL14864207LA0401X, 322D00000X, 3245S0500X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000024029Medicaid
AL51024029OtherBCBS HH LOCATIONS
AL51523698OtherBCBS MADISON SURG CTR
AL009975795Medicaid
AL051019925OtherBCBS- AL INDIV
AL51523698OtherBCBS MADISON SURG CTR
ALB64827Medicare UPIN
AL000024029Medicare ID - Type Unspecified