1386626547 NPI number — DR. LEANNE M WISNIEWSKI DO

Table of content: DR. LEANNE M WISNIEWSKI DO (NPI 1386626547)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386626547 NPI number — DR. LEANNE M WISNIEWSKI DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WISNIEWSKI
Provider First Name:
LEANNE
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DEWAN
Provider Other First Name:
LEANNE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1386626547
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:
27332 WOODWARD AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ROYAL OAK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48067-0927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-543-1545
Provider Business Mailing Address Fax Number:
246-543-8638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27332 WOODWARD AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROYAL OAK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48067-0927
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-543-1545
Provider Business Practice Location Address Fax Number:
246-543-8638
Provider Enumeration Date:
11/15/2005

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: 208000000X , with the licence number:  5101013066 , 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)





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