1164523197 NPI number — LESLEY HUFFMAN-DILG PA

Table of content: LESLEY HUFFMAN-DILG PA (NPI 1164523197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164523197 NPI number — LESLEY HUFFMAN-DILG PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUFFMAN-DILG
Provider First Name:
LESLEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUFFMAN
Provider Other First Name:
LESLEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164523197
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12655 OLIVE BLVD STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63141-6386
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-851-1075
Provider Business Mailing Address Fax Number:
314-851-4477

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13303 TESSON FERRY RD STE 45
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63128-4062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-748-5917
Provider Business Practice Location Address Fax Number:
314-748-5919
Provider Enumeration Date:
09/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  2005004539 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 196559 . This is a "BLUE CROSS OF MO" identifier . This identifiers is of the category "OTHER".




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