1336217066 NPI number — MARK LINUS LEITSCHUH MD

Table of content: MARK LINUS LEITSCHUH MD (NPI 1336217066)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336217066 NPI number — MARK LINUS LEITSCHUH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEITSCHUH
Provider First Name:
MARK
Provider Middle Name:
LINUS
Provider Name Prefix Text:
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:
1336217066
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4425 N PORT WASHINGTON RD
Provider Second Line Business Mailing Address:
ATTN: CSMCP CLINIC CREDENTIALING
Provider Business Mailing Address City Name:
GLENDALE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53212-1082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-243-3700
Provider Business Mailing Address Fax Number:
262-243-3701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13133 N PORT WASHINGTON RD
Provider Second Line Business Practice Location Address:
SUITE 122
Provider Business Practice Location Address City Name:
MEQUON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53097-2419
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-243-3700
Provider Business Practice Location Address Fax Number:
262-243-3701
Provider Enumeration Date:
12/01/2006

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: 207RC0000X , with the licence number:  31195 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31602900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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