1336244631 NPI number — LEIF ERIC LEAF PHD

Table of content: LEIF ERIC LEAF PHD (NPI 1336244631)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336244631 NPI number — LEIF ERIC LEAF PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAF
Provider First Name:
LEIF
Provider Middle Name:
ERIC
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEAF
Provider Other First Name:
ERIC
Provider Other Middle Name:
LEIF
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1336244631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13829 HARBOR DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNER SPRINGS
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-441-1640
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3515 S 4TH ST
Provider Second Line Business Practice Location Address:
PROFESSIONAL ASSOCIATION
Provider Business Practice Location Address City Name:
LEAVENWORTH
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
913-651-8415
Provider Business Practice Location Address Fax Number:
913-772-8580
Provider Enumeration Date:
09/13/2006

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: 103T00000X , with the licence number:  701 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103T00000X , with the licence number: 01356 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 119716 . This is a "BCBS OF KANSAS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 2094031 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 24103022 . This is a "BCBS OF KC KS" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 004517 . This is a "BCBS OF KANSAS GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 5240235 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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