Basic Information
| Provider Information | |||||||||
| NPI: | 1568450526 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEECH | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MB CHB PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 827783 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191857783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157074353 | ||||||||
| FaxNumber: | 2157072781 | ||||||||
| Practice Location | |||||||||
| Address1: | 3401 N BROAD ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191405103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157074353 | ||||||||
| FaxNumber: | 2157072781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 01/21/2010 | ||||||||
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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 | 207ZP0105X | MD 051231L | PA | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0014694770001 | 05 | PA | MEDICAID |