Provider Demographics
NPI:1750349296
Name:LEE, ANDY C (MD)
Entity type:Individual
Prefix:
First Name:ANDY
Middle Name:C
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 COLUMBUS RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:43019-1266
Mailing Address - Country:US
Mailing Address - Phone:740-694-1261
Mailing Address - Fax:740-694-7145
Practice Address - Street 1:122 COLUMBUS RD
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:OH
Practice Address - Zip Code:43019-1266
Practice Address - Country:US
Practice Address - Phone:740-694-1261
Practice Address - Fax:740-694-7145
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058967L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0828091Medicaid
OH0828091Medicaid
353077OtherSUBMITTER NUMBER
311098079OtherAETNA
OH000000118430OtherANTHEM
12476OtherCIGNA
12476OtherCIGNA
E81742Medicare UPIN
OH0828091Medicaid
OHH021131Medicare PIN
OH0828091Medicaid