MEDICARE: RENATO SIAZON LEE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	4301055115	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	080G360680	OTHER	MI	HEALTHPLUS OF MICHIGAN ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0807341122	OTHER	MI	BCBS OF MICHIGAN ID

General Provider Information

NPI Number	:	1114977725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENATO SIAZON LEE M.D.

Provider Business Mailing Address
First Line	:	611 W BELLE AVE
Second Line	:	PO BOX 160
City	:	SAINT CHARLES
State	:	MI
Zip	:	48655-1611
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	611 W BELLE AVE
Second Line	:
City	:	SAINT CHARLES
State	:	MI
Zip	:	48655-1611
Country	:	US
Telephone Number	:	989-865-9958
Fax Number	:	989-865-8099

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2006
Last Update Date	:	09/29/2009

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