1164496865 NPI number — DR. EDWARD LEON MD

Table of content: DR. EDWARD LEON MD (NPI 1164496865)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164496865 NPI number — DR. EDWARD LEON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEON
Provider First Name:
EDWARD
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1164496865
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2300 N EDWARD ST
Provider Second Line Business Mailing Address:
EMERGENCY DEPT
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62526-4163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-876-3000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2300 N EDWARD ST
Provider Second Line Business Practice Location Address:
EMERGENCY DEPT
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62526-4163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-876-3000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2006

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: 207P00000X , with the licence number:  0361409383 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 036109383001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: IL0181 . This is a "JOHN DEERE ILLINOIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 036109383 . This is a "BCILLINOIS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 225150 . This is a "IHS" identifier . This identifiers is of the category "OTHER".
  • Identifier: P00053389 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1582965 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 93334 . This is a "BCWELLMARK 7TH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 93378 . This is a "BCWELLMARK WEST" identifier . This identifiers is of the category "OTHER".




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