Basic Information
Provider Information | |||||||||
NPI: | 1316160971 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LESLIE MEDICAL CENTER P C | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 207 E BELLEVUE ST | ||||||||
Address2: |   | ||||||||
City: | LESLIE | ||||||||
State: | MI | ||||||||
PostalCode: | 492519373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5175898252 | ||||||||
FaxNumber: | 5175895189 | ||||||||
Practice Location | |||||||||
Address1: | 207 E BELLEVUE ST | ||||||||
Address2: |   | ||||||||
City: | LESLIE | ||||||||
State: | MI | ||||||||
PostalCode: | 492519373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5175898252 | ||||||||
FaxNumber: | 5175895189 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2007 | ||||||||
LastUpdateDate: | 03/22/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARUTI | ||||||||
AuthorizedOfficialFirstName: | TIMUR | ||||||||
AuthorizedOfficialMiddleName: | ANUM | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 5175898252 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | 4301052165 | MI | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
ID Information
ID | Type | State | Issuer | Description | 4741000 | 05 | MI |   | MEDICAID |