Basic Information
| Provider Information | |||||||||
| NPI: | 1841262938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEIDICH | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2134 N KANSAS AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679012012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2093399036 | ||||||||
| FaxNumber: | 2093391901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2134 N KANSAS AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERAL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 679012012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6206241500 | ||||||||
| FaxNumber: | 6206241501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 10/13/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 04-30944 | KS | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 200335440A | 05 | KS | MEDICAID | 100024200A | 05 | OK | MEDICAID |