Provider Demographics
NPI:1285963041
Name:LEE, MARY ELLEN
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1260
Mailing Address - Country:US
Mailing Address - Phone:207-907-4160
Mailing Address - Fax:207-907-4160
Practice Address - Street 1:727 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412-1260
Practice Address - Country:US
Practice Address - Phone:207-907-4160
Practice Address - Fax:207-907-4160
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME3002923OtherMAINECARE PROVIDER LICENSE NUMBER
ME432802900OtherMAINECARE BILLING NUMBER
MEVC0000112845OtherMAINECARE VENDOR NUMBER