Provider Demographics
NPI:1356367213
Name:LEE, KEVIN HARRY (DO)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:HARRY
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:574 ALLISON ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-2910
Mailing Address - Country:US
Mailing Address - Phone:989-600-0785
Mailing Address - Fax:541-789-6461
Practice Address - Street 1:574 ALLISON ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-2910
Practice Address - Country:US
Practice Address - Phone:989-600-0785
Practice Address - Fax:541-789-6461
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101008929207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3512728Medicaid
MIKL008929OtherBCBS
MI0P43930OtherMEDICARE GROUP
MI114982630Medicaid
MIKL008929OtherBCBS
MI0Z96017089Medicare PIN
MI0P43930OtherMEDICARE GROUP