Basic Information
| Provider Information | |||||||||
| NPI: | 1578564621 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEIPZIG | ||||||||
| FirstName: | LYLA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 77000 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482772000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864474171 | ||||||||
| FaxNumber: | 5864474180 | ||||||||
| Practice Location | |||||||||
| Address1: | 25319 LITTLE MACK AVE | ||||||||
| Address2: | |||||||||
| City: | ST CLAIR SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480813370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864474000 | ||||||||
| FaxNumber: | 5864474009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301025420 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3517386 | 05 | MI | MEDICAID |