Provider Demographics
NPI:1013930577
Name:LEE, EDWARD K (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:K
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-391-1830
Mailing Address - Fax:616-391-1286
Practice Address - Street 1:1840 WEALTHY ST SE
Practice Address - Street 2:
Practice Address - City:EAST GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-2921
Practice Address - Country:US
Practice Address - Phone:616-774-7845
Practice Address - Fax:616-774-5146
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-10-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI51010075802085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4148311Medicaid
MI4148311Medicaid
MID16289009Medicare PIN