Provider Demographics
NPI:1518938372
Name:EDGEWATER INTERNAL MEDICINE ASSOC. INC.
Entity Type:Organization
Organization Name:EDGEWATER INTERNAL MEDICINE ASSOC. INC.
Other - Org Name:LESLIE M LEE MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-428-4640
Mailing Address - Street 1:2568 SOUTH RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32111-7535
Mailing Address - Country:US
Mailing Address - Phone:386-428-4640
Mailing Address - Fax:386-426-1409
Practice Address - Street 1:2568 S. RIDGEWOOD AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141-7535
Practice Address - Country:US
Practice Address - Phone:386-428-4640
Practice Address - Fax:386-426-1409
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDGEWATER INTERNAL MEDICINE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-30
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0063341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
23541OtherBCBS
K7444Medicare ID - Type Unspecified
F69008Medicare UPIN