Basic Information
| Provider Information | |||||||||
| NPI: | 1831191592 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEIS | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E LIBERTY ST STE 800 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402021428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024473242 | ||||||||
| FaxNumber: | 5024484722 | ||||||||
| Practice Location | |||||||||
| Address1: | 5129 DIXIE HWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402161727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024473242 | ||||||||
| FaxNumber: | 5024484722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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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 | 207Q00000X | 17976 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100468890 | 05 | KY | MEDICAID |