Basic Information
| Provider Information | |||||||||
| NPI: | 1760407258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | LESLEY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | LESLEY | ||||||||
| OtherMiddleName: | ANN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 776351 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606776351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5029696552 | ||||||||
| FaxNumber: | 5022121358 | ||||||||
| Practice Location | |||||||||
| Address1: | 12615 TAYLORSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402994452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022611595 | ||||||||
| FaxNumber: | 5022611590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 05/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 40032 | KY | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 40032 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000486608 | 01 | KY | ANTHEM FOR NCMA TYLER | OTHER | 200865590 | 05 | IN | MEDICAID | 284510500 | 01 | KY | PAD NMCA TYLER | OTHER | 64125339 | 05 | KY | MEDICAID | P00388569 | 01 | KY | RAILROAD MEDICARE | OTHER | 50014893 | 01 | KY | PASSPORT NMCA TYLER | OTHER |