1841299179 NPI number — DR. JAMES D LEEDLE DO

Table of content: DR. JAMES D LEEDLE DO (NPI 1841299179)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841299179 NPI number — DR. JAMES D LEEDLE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEEDLE
Provider First Name:
JAMES
Provider Middle Name:
D
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1841299179
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11460 HIGHLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARTLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48353-2710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-632-7700
Provider Business Mailing Address Fax Number:
810-632-9770

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11460 HIGHLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48353-2710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-632-7700
Provider Business Practice Location Address Fax Number:
810-632-9770
Provider Enumeration Date:
07/19/2005

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: 111N00000X , with the licence number:  095579 , 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)

  • Identifier: 950D700080 . This is a "BC/BS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P77386 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 123473 . This is a "CARE CHOICES PPO" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 123473 . This is a "PREFERRED CHOICES" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 290825 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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