Provider Demographics
NPI:1487073433
Name:MEDELLIN, JOSEPH LEE (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LEE
Last Name:MEDELLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4442 PENINSULA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-7803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 W BIG BEAVER RD STE 300
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4725
Practice Address - Country:US
Practice Address - Phone:810-331-0989
Practice Address - Fax:855-850-4055
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD464546207Q00000X
390200000X
MI4301500490207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program