1871716746 NPI number — EDWARD W LEAHEY MD PROFESSIONAL ASSOCIATION

Table of content: (NPI 1871716746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871716746 NPI number — EDWARD W LEAHEY MD PROFESSIONAL ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDWARD W LEAHEY MD PROFESSIONAL ASSOCIATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ED LEAHEY MD PA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871716746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4201 GARTH RD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAYTOWN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77521-3154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-422-3113
Provider Business Mailing Address Fax Number:
281-427-6289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4201 GARTH RD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAYTOWN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77521-3154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-422-3113
Provider Business Practice Location Address Fax Number:
281-427-6289
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LEAHEY
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
ABBY
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
832-385-1631

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  E9763 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 180530102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF1985 . This is a "MEDICARE RR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0095PV . This is a "BC/BS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 009337 . This is a "MEDICARE GROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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