Provider Demographics
NPI:1639151871
Name:LEAN, ERIC L (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:LEAN
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 1:1903 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-5200
Mailing Address - Country:US
Mailing Address - Phone:269-387-3290
Mailing Address - Fax:269-387-2944
Practice Address - Street 1:1903 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-5200
Practice Address - Country:US
Practice Address - Phone:269-387-3290
Practice Address - Fax:269-387-2944
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301075289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4625261Medicaid
MIC30861OtherRAILROAD MEDICARE
700C947350OtherBLUE CROSS GROUP
0803913831OtherBLUE CROSS INDIVIDUAL
MIM20520047Medicare PIN
0M22440027Medicare PIN
MIC30861OtherRAILROAD MEDICARE
MI4625261Medicaid