Provider Demographics
NPI:1932180817
Name:LEE, MARY S (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:S
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5799 W MAPLE RD STE 163
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-4458
Mailing Address - Country:US
Mailing Address - Phone:248-419-5111
Mailing Address - Fax:248-419-5112
Practice Address - Street 1:5799 W MAPLE RD STE 163
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-4458
Practice Address - Country:US
Practice Address - Phone:248-419-5111
Practice Address - Fax:248-419-5112
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301061252208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598296485Medicaid