Basic Information
| Provider Information | |||||||||
| NPI: | 1124000310 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANK | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 MITCHELL AVE. | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077720639 | ||||||||
| FaxNumber: | 6077720639 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 MITCHELL AVE | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077720639 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 07/11/2011 | ||||||||
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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 | 207R00000X | 173774 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 173774 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 01108410 | 05 | NY | MEDICAID |