Provider Demographics
NPI:1720086317
Name:LEE, SUE J (MD)
Entity Type:Individual
Prefix:DR
First Name:SUE
Middle Name:J
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5653 FRIST BLVD
Mailing Address - Street 2:SUITE 530
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076
Mailing Address - Country:US
Mailing Address - Phone:615-885-1093
Mailing Address - Fax:615-885-1110
Practice Address - Street 1:5653 FRIST BLVD
Practice Address - Street 2:SUITE 530
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076
Practice Address - Country:US
Practice Address - Phone:615-885-1093
Practice Address - Fax:615-885-1110
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24454174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3707485Medicaid
TN3075603Medicaid
TN62-1612525OtherTAX INDENTIFICATION #
TN3075603Medicaid
TN62-1612525OtherTAX INDENTIFICATION #
D45915Medicare UPIN