Provider Demographics
NPI:1043320252
Name:LEE, BOTHWELL GRAVES (MD)
Entity type:Individual
Prefix:DR
First Name:BOTHWELL
Middle Name:GRAVES
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 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:800-749-5191
Mailing Address - Fax:
Practice Address - Street 1:1630 WOODBROOKE DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-8501
Practice Address - Country:US
Practice Address - Phone:410-912-6330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101221427207T00000X
MDD0057234207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD581314YTQMedicaid
490689Medicare PIN
VAB-76461Medicare UPIN