Provider Demographics
NPI:1649240136
Name:LIM LEE, MARY A (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:A
Last Name:LIM LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6746 DICK FLYNN BLVD
Mailing Address - Street 2:P.O. BOX 500
Mailing Address - City:GOSHEN
Mailing Address - State:OH
Mailing Address - Zip Code:45122-8609
Mailing Address - Country:US
Mailing Address - Phone:513-722-2603
Mailing Address - Fax:513-722-3423
Practice Address - Street 1:6746 DICK FLYNN BLVD
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:OH
Practice Address - Zip Code:45122-8609
Practice Address - Country:US
Practice Address - Phone:513-722-2603
Practice Address - Fax:513-722-3423
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35041350207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0344041Medicaid
OH0344041Medicaid
OH0438162Medicare PIN