Basic Information
| Provider Information | |||||||||
| NPI: | 1710088570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLSTEIN | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 64442 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212644442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103280345 | ||||||||
| FaxNumber: | 4103283577 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 S GREENE ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212011544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103280345 | ||||||||
| FaxNumber: | 4103283577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 04/13/2009 | ||||||||
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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 | 208000000X | D0064920 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | D64920 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 411854500 | 05 | MD | MEDICAID | S062-0339 | 01 | MD | BLUE CHOICE - REGIONAL | OTHER | 927948-01 | 01 | MD | BLUE SHIELD - MD | OTHER |