Basic Information
| Provider Information | |||||||||
| NPI: | 1225018302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HISE | ||||||||
| FirstName: | LEO | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 2183626908 | ||||||||
| Practice Location | |||||||||
| Address1: | 3605 MAYFAIR AVE | ||||||||
| Address2: | |||||||||
| City: | HIBBING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557462935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182623441 | ||||||||
| FaxNumber: | 2183626908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2006 | ||||||||
| LastUpdateDate: | 01/03/2017 | ||||||||
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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 | 207X00000X | A-1685-12 | NM | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | A-1685-12 | NM | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XS0106X | A-1685-12 | NM | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XX0005X | A-1685-12 | NM | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XX0801X | A-1685-12 | NM | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma | 207X00000X | 37803 | MN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 37803 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 207XX0005X | 37803 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207XS0114X | 37803 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 207XP3100X | 37803 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Pediatric Orthopaedic Surgery | 207XX0801X | 37803 | MN | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Trauma |
ID Information
| ID | Type | State | Issuer | Description | 71551336 | 05 | NM | MEDICAID |