Healthcare Provider Details

I. General information

NPI: 1669566303
Provider Name (Legal Business Name): LEE EVERETT EDSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY SUITE 460
PROVIDENCE RI
02905
US

IV. Provider business mailing address

2 DUDLEY SUITE 460
PROVIDENCE RI
02905
US

V. Phone/Fax

Practice location:
  • Phone: 401-331-2303
  • Fax: 401-331-4430
Mailing address:
  • Phone: 401-331-2303
  • Fax: 401-331-4430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number5949
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: