Provider Demographics
NPI:1053522771
Name:MARK LEE NEUROSURGERY, LLC
Entity type:Organization
Organization Name:MARK LEE NEUROSURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-721-2624
Mailing Address - Street 1:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2828
Mailing Address - Country:US
Mailing Address - Phone:706-868-0131
Mailing Address - Fax:706-854-0131
Practice Address - Street 1:1446 HARPER ST
Practice Address - Street 2:BT5730
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0012
Practice Address - Country:US
Practice Address - Phone:706-721-2624
Practice Address - Fax:706-721-2652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039515207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPA945Medicaid
GAGRP8134OtherMEDICARE GROUP