1194795187 NPI number — LESLIE G MACAULEY MD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194795187 NPI number — LESLIE G MACAULEY MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LESLIE G MACAULEY MD PC
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:
LESLIE G MACAULEY MD PC
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:
1194795187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
611 COURT STREET
Provider Business Mailing Address City Name:
WEST BRANCH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48661-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-595-1090
Provider Business Mailing Address Fax Number:
989-345-5803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4970 NORTHWIND DR
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-5080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-333-7115
Provider Business Practice Location Address Fax Number:
517-333-6771
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACAULEY
Authorized Official First Name:
LESLIE
Authorized Official Middle Name:
GREENE
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
517-333-7115

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  4301062299 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4455930 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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