1396767414 NPI number — LESLIE JOHN SALLOUM, MD, PA

Table of content: (NPI 1396767414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396767414 NPI number — LESLIE JOHN SALLOUM, MD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LESLIE JOHN SALLOUM, MD, PA
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:
1396767414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
921 S LONG DR
Provider Second Line Business Mailing Address:
SUITE 208
Provider Business Mailing Address City Name:
ROCKINGHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28379-4874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-417-3540
Provider Business Mailing Address Fax Number:
910-417-3542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
921 S LONG DR
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
ROCKINGHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28379-4874
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-417-3540
Provider Business Practice Location Address Fax Number:
910-417-3542
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SALLOUM
Authorized Official First Name:
LESLIE
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-417-3540

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  200301519 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8913506 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 13506 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: DC2516 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".




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