=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376573832
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVY M LEE MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 12/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 514 W 2ND ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47403-2316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-353-3719
-----------------------------------------------------
Fax | 812-353-3713
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 N SHADELAND AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46219-4959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 01049528
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RH0002X
-----------------------------------------------------
Taxonomy Name | Hospice and Palliative Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 01049528A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------