1114347440 NPI number — LESLEY BRODIE, M.D., P.C.

Table of content: (NPI 1114347440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114347440 NPI number — LESLEY BRODIE, M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LESLEY BRODIE, M.D., P.C.
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:
Provider Other Organization Name Type Code:
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:
1114347440
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 766
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05254-0766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-367-1068
Provider Business Mailing Address Fax Number:
802-367-1069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
82 ELM STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER CENTER
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05255-9642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-367-1068
Provider Business Practice Location Address Fax Number:
802-367-1069
Provider Enumeration Date:
04/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BRODIE
Authorized Official First Name:
LESLEY
Authorized Official Middle Name:
THOMPSON
Authorized Official Title or Position:
OFFICER/MEMBER
Authorized Official Telephone Number:
802-367-1068

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  042.0012150 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X , with the licence number: 042.0012150 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1019286 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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