Basic Information
| Provider Information | |||||||||
| NPI: | 1114074929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | POLLACK | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 3500 FIFTEEN MILE ROAD | ||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869779936 | ||||||||
| FaxNumber: | 5869776498 | ||||||||
| Practice Location | |||||||||
| Address1: | HENRY FORD HEALTH SYSTEM | ||||||||
| Address2: | 3500 FIFTEEN MILE ROAD | ||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5869779936 | ||||||||
| FaxNumber: | 5869776498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 4301053419 | MI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | LP053419 | 01 | COMMERCIAL-COMMERCIAL NUMBER | OTHER | 192569410 | 05 | MI | MEDICAID | 700H262280 | 01 | BLUE CROSS-BLUE CROSS | OTHER | LP053419 | 01 | CHAMPUS-CHAMPUS | OTHER |