1245218254 NPI number — TODD G LEECH PA-C

Table of content: TODD G LEECH PA-C (NPI 1245218254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245218254 NPI number — TODD G LEECH PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEECH
Provider First Name:
TODD
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

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:
1245218254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 JACKSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT PAUL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55101-2502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-254-4786
Provider Business Mailing Address Fax Number:
651-254-9426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 S 2ND ST STE 180
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55454-5000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-625-1562
Provider Business Practice Location Address Fax Number:
612-626-8311
Provider Enumeration Date:
01/09/2006

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:  9204 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0111791 . This is a "MEDICA (MN)" identifier . This identifiers is of the category "OTHER".
  • Identifier: NA2951023880 . This is a "PREFERRED ONE (MN)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 874112 . This is a "AMERICA'S PPO (MN)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0966523 . This is a "MEDICAID (IOWA)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 120314 . This is a "UCARE (MN)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 281724100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 73A65LE . This is a "BCBS (MN)" identifier . This identifiers is of the category "OTHER".
  • Identifier: HP41032 . This is a "HEALTH PARTNERS (MN)" identifier . This identifiers is of the category "OTHER".
  • Identifier: 970005979 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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