1467569079 NPI number — DR. LESLIE ANN CHEESEMAN M.D.

Table of content: DR. LESLIE ANN CHEESEMAN M.D. (NPI 1467569079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467569079 NPI number — DR. LESLIE ANN CHEESEMAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHEESEMAN
Provider First Name:
LESLIE
Provider Middle Name:
ANN
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:
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:
1467569079
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 S BROAD ST
Provider Second Line Business Mailing Address:
SUITE 360
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19146-1613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-685-6769
Provider Business Mailing Address Fax Number:
215-685-6732

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
555 S 43RD ST
Provider Second Line Business Practice Location Address:
HEALTH CARE CENTER #3
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-685-7504
Provider Business Practice Location Address Fax Number:
215-685-7551
Provider Enumeration Date:
08/23/2006

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: 207R00000X , with the licence number:  MD067659L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01-01803252 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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