Basic Information
| Provider Information | |||||||||
| NPI: | 1770585440 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 102 N PINE ST | ||||||||
| Address2: | BLUE HILL CLINIC | ||||||||
| City: | BLUE HILL | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689305532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027562141 | ||||||||
| FaxNumber: | 4027562142 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 N PINE ST | ||||||||
| Address2: | BLUE HILL CLINIC | ||||||||
| City: | BLUE HILL | ||||||||
| State: | NE | ||||||||
| PostalCode: | 689305532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4027562141 | ||||||||
| FaxNumber: | 4027562142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 03/29/2010 | ||||||||
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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 | 174400000X | 13349 | NE | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 06154 | 01 | NE | BLUE CROSS BLUE SHIELD NE | OTHER | 096853006 | 01 | MEDICARE PTAN | OTHER |