Provider Demographics
NPI:1518014158
Name:NELLIE LEE M.D., P.A.
Entity Type:Organization
Organization Name:NELLIE LEE M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-440-3366
Mailing Address - Street 1:190 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07660-1742
Mailing Address - Country:US
Mailing Address - Phone:201-440-3366
Mailing Address - Fax:201-807-0705
Practice Address - Street 1:190 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07660-1742
Practice Address - Country:US
Practice Address - Phone:201-440-3366
Practice Address - Fax:201-807-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02733100207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2998301Medicaid
LE117105Medicare ID - Type Unspecified
NJ2998301Medicaid