1063619260 NPI number — DR. HOLLY MICHELE LEEMAN M.D.

Table of content: DR. HOLLY MICHELE LEEMAN M.D. (NPI 1063619260)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063619260 NPI number — DR. HOLLY MICHELE LEEMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEEMAN
Provider First Name:
HOLLY
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALESTRIERI
Provider Other First Name:
HOLLY
Provider Other Middle Name:
MICHELE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063619260
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 BIRDS HILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEEDHAM
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02492-4240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-708-6279
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 LIBBEY PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
WEYMOUTH
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02189
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
339-201-4120
Provider Business Practice Location Address Fax Number:
339-201-4122
Provider Enumeration Date:
06/29/2007

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: 207V00000X , with the licence number:  252569 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110094185A , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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