Basic Information
Provider Information | |||||||||
NPI: | 1104060086 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARNES | ||||||||
FirstName: | LESLIE | ||||||||
MiddleName: | ANNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FINK | ||||||||
OtherFirstName: | LESLIE | ||||||||
OtherMiddleName: | ANNE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2450 W HUNTING PARK AVE | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191291302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157072111 | ||||||||
FaxNumber: | 2157072324 | ||||||||
Practice Location | |||||||||
Address1: | 3401 N BROAD ST | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191405103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2157072111 | ||||||||
FaxNumber: | 2157072324 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2009 | ||||||||
LastUpdateDate: | 03/21/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 273748 | NY | N |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   | 207X00000X | MD455672 | PA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 04015909 | 05 | NY |   | MEDICAID |