Healthcare Provider Details

I. General information

NPI: 1306077672
Provider Name (Legal Business Name): ROBERT B LEE MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 CHADWICK DR SUITE 352
JACKSON MS
39204-3463
US

IV. Provider business mailing address

PO BOX 3528
JACKSON MS
39207-3528
US

V. Phone/Fax

Practice location:
  • Phone: 601-936-6001
  • Fax: 601-936-4389
Mailing address:
  • Phone: 601-936-6001
  • Fax: 601-936-4389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number10711
License Number StateMS

VIII. Authorized Official

Name: ROBERT B LEE
Title or Position: OWNER
Credential: MD
Phone: 601-936-6001