Provider Demographics
NPI:1699757831
Name:LEAN, EDWARD WILLIAM JR (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:WILLIAM
Last Name:LEAN
Suffix:JR
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 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:535 S BURDICK ST
Practice Address - Street 2:SUITE 245
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5294
Practice Address - Country:US
Practice Address - Phone:269-341-8822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301028347207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1699757831Medicaid
MI1417961137OtherBCBSM - BMH
MI105177309Medicaid
MI700H060020OtherBCBSM
MI1417961137OtherBCBSM - BMH
B43741Medicare UPIN
MI105177309Medicaid