1194795187 NPI number — LESLIE G MACAULEY MD PC

Table of content: (NPI 1194795187)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194795187 NPI number — LESLIE G MACAULEY MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LESLIE G MACAULEY MD PC
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:
LESLIE G MACAULEY MD PC
Provider Other Organization Name Type Code:
3
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:
1194795187
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 428
Provider Second Line Business Mailing Address:
611 COURT STREET
Provider Business Mailing Address City Name:
WEST BRANCH
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48661-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-595-1090
Provider Business Mailing Address Fax Number:
989-345-5803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4970 NORTHWIND DR
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
EAST LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48823-5080
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-333-7115
Provider Business Practice Location Address Fax Number:
517-333-6771
Provider Enumeration Date:
01/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MACAULEY
Authorized Official First Name:
LESLIE
Authorized Official Middle Name:
GREENE
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
517-333-7115

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  4301062299 , 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: 4455930 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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