Provider Demographics
NPI:1528079969
Name:LEE, MARK KEITH (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:KEITH
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 1:100 LANTANA ROAD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-1903
Mailing Address - Country:US
Mailing Address - Phone:931-484-5141
Mailing Address - Fax:931-484-5620
Practice Address - Street 1:100 LANTANA ROAD
Practice Address - Street 2:SUITE 202
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-1903
Practice Address - Country:US
Practice Address - Phone:931-484-5141
Practice Address - Fax:931-484-5620
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD17713207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN139003OtherBLUE CROSS
TN3067149Medicaid
TN3067149Medicaid
TN3067140Medicare ID - Type Unspecified
D98388Medicare UPIN