1760407258 NPI number — LESLEY A HARRIS MD

Table of content: LESLEY A HARRIS MD (NPI 1760407258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760407258 NPI number — LESLEY A HARRIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRIS
Provider First Name:
LESLEY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
LESLEY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1760407258
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 776351
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60677-6351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-969-6552
Provider Business Mailing Address Fax Number:
502-212-1358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12615 TAYLORSVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40299-4452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-261-1595
Provider Business Practice Location Address Fax Number:
502-261-1590
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  40032 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 40032 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000486608 . This is a "ANTHEM FOR NCMA TYLER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 200865590 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 284510500 . This is a "PAD NMCA TYLER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 64125339 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00388569 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 50014893 . This is a "PASSPORT NMCA TYLER" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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