Provider Demographics
NPI:1912005919
Name:LEE, MARK ALFRED (MPT, OMPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALFRED
Last Name:LEE
Suffix:
Gender:M
Credentials:MPT, OMPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26295 PATTOW ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3561
Mailing Address - Country:US
Mailing Address - Phone:586-771-9525
Mailing Address - Fax:
Practice Address - Street 1:24011 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3115
Practice Address - Country:US
Practice Address - Phone:248-557-5440
Practice Address - Fax:248-557-2305
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008453225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23-6562Medicare ID - Type Unspecified