Provider Demographics
NPI:1902905839
Name:LEE MEDICAL CLINIC SC
Entity Type:Organization
Organization Name:LEE MEDICAL CLINIC SC
Other - Org Name:LEGAL BUSINESS NAME
Other - Org Type:Other Name
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-616-8901
Mailing Address - Street 1:7114 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2052
Mailing Address - Country:US
Mailing Address - Phone:414-616-8901
Mailing Address - Fax:414-616-8906
Practice Address - Street 1:7114 W. CAPITOL DRIVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216
Practice Address - Country:US
Practice Address - Phone:414-616-8901
Practice Address - Fax:414-616-8906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42508020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34066500Medicaid
WI000101546Medicare PIN
WI000001546Medicare ID - Type Unspecified
WI34066500Medicaid
H33409Medicare UPIN