Basic Information
| Provider Information | |||||||||
| NPI: | 1134128077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | RILLENS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 423 PECAN PARK DR | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395202514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284673449 | ||||||||
| FaxNumber: | 2284671975 | ||||||||
| Practice Location | |||||||||
| Address1: | 179 DRINKWATER RD | ||||||||
| Address2: | |||||||||
| City: | BAY ST LOUIS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395201613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2284670298 | ||||||||
| FaxNumber: | 2284671975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 08095 | MS | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0118499 | 05 | MS | MEDICAID |