1700989233 NPI number — ERIC J LEESTMA

Table of content: ERIC J LEESTMA (NPI 1700989233)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700989233 NPI number — ERIC J LEESTMA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEESTMA
Provider First Name:
ERIC
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1700989233
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 850
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMOTTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46310-0850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
219-987-7750
Provider Business Mailing Address Fax Number:
219-987-5750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
519 N HALLECK
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMOTTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
219-987-7750
Provider Business Practice Location Address Fax Number:
219-987-5750
Provider Enumeration Date:
09/07/2006

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: 207Q00000X , with the licence number:  02000641A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100209310A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36655 . This is a "INDIANA HEALTH NETWORK" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000084931 . This is a "ANTHEM BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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