Provider Demographics
NPI:1922098714
Name:TYNE, LEE M (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:M
Last Name:TYNE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19475 W NORTH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4199
Mailing Address - Country:US
Mailing Address - Phone:262-780-4400
Mailing Address - Fax:262-780-4425
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8600
Practice Address - Fax:414-328-8686
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI17462020207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31226200Medicaid
WICG1663Medicare PIN
WI31226200Medicaid