Provider Demographics
NPI:1699873299
Name:HEERY, LEE BRUCE (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:BRUCE
Last Name:HEERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 WELLNESS WAY
Mailing Address - Street 2:SUITE 7230
Mailing Address - City:ST. SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2286
Mailing Address - Country:US
Mailing Address - Phone:912-634-2795
Mailing Address - Fax:912-638-5636
Practice Address - Street 1:7000 WELLNESS WAY
Practice Address - Street 2:SUITE 7230
Practice Address - City:ST. SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2286
Practice Address - Country:US
Practice Address - Phone:912-634-2795
Practice Address - Fax:912-638-5636
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040095208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891246NMedicaid
NC891246NMedicaid