Provider Demographics
NPI:1497882724
Name:LEE, KEVIN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD
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 1:29275 NORTHWESTERN HWY
Mailing Address - Street 2:STE. 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034
Mailing Address - Country:US
Mailing Address - Phone:877-784-3667
Mailing Address - Fax:248-869-3982
Practice Address - Street 1:136 S PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-3349
Practice Address - Country:US
Practice Address - Phone:248-926-4292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057469207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4363382Medicaid
MI1406336402OtherBCBS
MIE93972Medicare UPIN
MI0N39530Medicare PIN