Basic Information
| Provider Information | |||||||||
| NPI: | 1922081348 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAO | ||||||||
| FirstName: | LEIGH | ||||||||
| MiddleName: | CHIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1516 MERGANSER BLVD | ||||||||
| Address2: | |||||||||
| City: | SWANSEA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622268539 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 SAINT ANTHONYS WAY | ||||||||
| Address2: | ST. ANTHONY'S HEALTH CENTER | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620024568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184652571 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 12/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/09/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 112947 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 036.102496 | IL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 036102496 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036102496 | 05 | IL | MEDICAID | 036102496-4 | 05 | IL | MEDICAID | 203922026 | 05 | MO | MEDICAID | 203922067 | 05 | IL | MEDICAID |