Healthcare Provider Details

I. General information

NPI: 1104826973
Provider Name (Legal Business Name): JAE YOUNG LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 01/14/2011
Certification Date:
Deactivation Date: 03/21/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

130 WASHINGTON ST
MARINE CITY MI
48039-1680
US

IV. Provider business mailing address

130 WASHINGTON ST
MARINE CITY MI
48039-1680
US

V. Phone/Fax

Practice location:
  • Phone: 810-765-8844
  • Fax: 810-765-4326
Mailing address:
  • Phone: 810-765-8844
  • Fax: 810-765-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301033400
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: