Basic Information
| Provider Information | |||||||||
| NPI: | 1699757831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEAN | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 JOHN ST | ||||||||
| Address2: | BOX 42 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693417806 | ||||||||
| FaxNumber: | 2693418743 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 S BURDICK ST | ||||||||
| Address2: | SUITE 245 | ||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490075294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693418822 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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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 | 207Q00000X | 4301028347 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 4301028347 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1699757831 | 05 | MI | MEDICAID | 1417961137 | 01 | MI | BCBSM - BMH | OTHER | 105177309 | 05 | MI | MEDICAID | 700H060020 | 01 | MI | BCBSM | OTHER |