Healthcare Provider Details

I. General information

NPI: 1043373517
Provider Name (Legal Business Name): MARY A LEE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6746 DICK FLYNN BLVD
GOSHEN OH
45122-8609
US

IV. Provider business mailing address

6746 DICK FLYNN BLVD
GOSHEN OH
45122-8609
US

V. Phone/Fax

Practice location:
  • Phone: 513-722-2603
  • Fax: 513-722-3423
Mailing address:
  • Phone: 513-722-2603
  • Fax: 513-722-3423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35041350
License Number StateOH

VIII. Authorized Official

Name: DR. MARY A LEE
Title or Position: PRESIDENT
Credential: MD
Phone: 513-722-2603