Provider Demographics
NPI:1255310363
Name:LEE, CHARLES IVY (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:IVY
Last Name:LEE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 WHITESBURG DR SE STE 103
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-1677
Mailing Address - Country:US
Mailing Address - Phone:256-715-8193
Mailing Address - Fax:
Practice Address - Street 1:4601 WHITESBURG DR SE STE 103
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-1677
Practice Address - Country:US
Practice Address - Phone:256-715-8193
Practice Address - Fax:256-715-8195
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00014864207L00000X
AL14864207LA0401X, 208D00000X, 3245S0500X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LA0401XAllopathic & Osteopathic PhysiciansAnesthesiologyAddiction Medicine
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51523698OtherBCBS MADISON SURG CTR
AL051019925OtherBCBS- AL INDIV
AL000024029Medicaid
AL009975795Medicaid
AL51024029OtherBCBS HH LOCATIONS
AL51523698OtherBCBS MADISON SURG CTR
ALB64827Medicare UPIN
AL000024029Medicare ID - Type Unspecified