Provider Demographics
NPI:1487606083
Name:LEE, THOMAS MARTIN (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:MARTIN
Last Name:LEE
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 PILGRIM BLVD
Practice Address - Street 2:
Practice Address - City:HARTFORD CITY
Practice Address - State:IN
Practice Address - Zip Code:47348-1382
Practice Address - Country:US
Practice Address - Phone:765-348-5776
Practice Address - Fax:765-348-3088
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01030229207Q00000X
IN01030229A207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00049764OtherRR MEDICARE
INP00968556OtherRR MEDICARE
IN100059570Medicaid
INP00968556OtherRR MEDICARE
IN100059570Medicaid
INM400054031Medicare PIN