Basic Information
Provider Information | |||||||||
NPI: | 1518924281 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEONARD | ||||||||
FirstName: | LORI | ||||||||
MiddleName: | R. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KLEINSCHMIDT | ||||||||
OtherFirstName: | LORI | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6751N CHESTNUT ST | ||||||||
Address2: |   | ||||||||
City: | RAVENNA | ||||||||
State: | OH | ||||||||
PostalCode: | 442663903 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3302963641 | ||||||||
FaxNumber: | 3302965297 | ||||||||
Practice Location | |||||||||
Address1: | 8819 COMMONS BLVD # 100 | ||||||||
Address2: |   | ||||||||
City: | TWINSBURG | ||||||||
State: | OH | ||||||||
PostalCode: | 440872177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3304252212 | ||||||||
FaxNumber: | 3304252779 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2006 | ||||||||
LastUpdateDate: | 07/29/2015 | ||||||||
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 | 207Q00000X | 34006358L | OH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2065723 | 05 | OH |   | MEDICAID |