MEDICARE: RAYMOND D LEECH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor		MS

General Provider Information

NPI Number	:	1568953115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND D LEECH

Provider Business Mailing Address
First Line	:	618 22ND ST S
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39701-6606
Country	:	US
Telephone Number	:	662-574-1265
Fax Number	:	662-630-5077

Provider Business Practice Location Address
First Line	:	618 22ND ST S
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39701-6606
Country	:	US
Telephone Number	:	662-574-1265
Fax Number	:	662-630-5077

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/18/2018
Last Update Date	:	05/18/2018

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Directions to “ RAYMOND D LEECH ” Practice Location

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