1417268764 NPI number — BRUCE C LEITKAM DO PC

Table of content: (NPI 1417268764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417268764 NPI number — BRUCE C LEITKAM DO PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUCE C LEITKAM DO 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:
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:
1417268764
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
490 W BROAD ST
Provider Second Line Business Mailing Address:
PO BOX 605
Provider Business Mailing Address City Name:
LINDEN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48451-8862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-735-1231
Provider Business Mailing Address Fax Number:
810-735-1092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
490 W BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINDEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48451-8862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-735-1231
Provider Business Practice Location Address Fax Number:
810-735-1092
Provider Enumeration Date:
07/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
LEITKAM
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
CALVIN
Authorized Official Title or Position:
OWNE
Authorized Official Telephone Number:
810-735-1231

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  BL006591 , 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: 1552457 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5251061 . This is a "BCBS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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