1578586566 NPI number — MR. CRAIG PAUL LEONARD MSPT

Table of content: KELLEY JOE BRADFORD PD (NPI 1457684730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578586566 NPI number — MR. CRAIG PAUL LEONARD MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEONARD
Provider First Name:
CRAIG
Provider Middle Name:
PAUL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1578586566
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1585 WILLOW POND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YARDLEY
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19067-5793
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-676-4070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2869 HOLME AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19152-2118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-676-4070
Provider Business Practice Location Address Fax Number:
215-676-4071
Provider Enumeration Date:
07/25/2006

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: 174400000X , with the licence number:  PT008976L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2004000000 . This is a "KEYSTONE HEALTH PLAN EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: PA BLUE SHIELD . This is a "1311180" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 045559PRL . This is a "MEDICARE ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2004000000 . This is a "AMERIHEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2563889 . This is a "AETNA/ US HEALTH CARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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