Healthcare Provider Details

I. General information

NPI: 1538110200
Provider Name (Legal Business Name): MARION O LEE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 03/12/2021
Certification Date: 03/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 N 5TH ST SUITE D
CORDELE GA
31015-3254
US

IV. Provider business mailing address

2773 MARSHALL DR
TIFTON GA
31793-8101
US

V. Phone/Fax

Practice location:
  • Phone: 229-391-2910
  • Fax: 229-386-4770
Mailing address:
  • Phone: 229-238-0121
  • Fax: 229-238-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number37596
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number37596
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: