Provider Demographics
NPI:1376755710
Name:LEE, MARYANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARYANN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SOUTH AVE
Mailing Address - Street 2:SUITE 307
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3529
Mailing Address - Country:US
Mailing Address - Phone:718-698-3777
Mailing Address - Fax:718-698-8777
Practice Address - Street 1:1200 SOUTH AVE
Practice Address - Street 2:SUITE 307
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3413
Practice Address - Country:US
Practice Address - Phone:718-698-3777
Practice Address - Fax:718-698-8777
Is Sole Proprietor?:No
Enumeration Date:2007-05-06
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07938600207R00000X
NY239954207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00717999RAILROADOtherMEDICARE RAILROAD
NYP00717999RAILROADOtherMEDICARE RAILROAD