Basic Information
| Provider Information | |||||||||
| NPI: | 1932355328 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEAHY | ||||||||
| FirstName: | IAN | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1812 MARSH RD | ||||||||
| Address2: | STORE 505 | ||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198104581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3027930432 | ||||||||
| FaxNumber: | 3027930400 | ||||||||
| Practice Location | |||||||||
| Address1: | 207 STADIUM ST | ||||||||
| Address2: | |||||||||
| City: | SMYRNA | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199772899 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026590173 | ||||||||
| FaxNumber: | 3026590424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 03/02/2010 | ||||||||
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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 | 225100000X | J10002392 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 3634428000 | 01 | IBC AMERIHEALTH | OTHER | 1932355328 | 05 | DE | MEDICAID |