MEDICARE: MITCHELL HUGH LEAVITT M.D.

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	207P00000X	Emergency Medicine Physician	25639	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	009	OTHER	WI	BCBS

General Provider Information

NPI Number	:	1598752719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITCHELL HUGH LEAVITT M.D.

Provider Business Mailing Address
First Line	:	8001 RIDGES RD
Second Line	:
City	:	BAILEYS HARBOR
State	:	WI
Zip	:	54202-9362
Country	:	US
Telephone Number	:	941-204-9149
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 W OKLAHOMA AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53215-4330
Country	:	US
Telephone Number	:	414-649-6588
Fax Number	:	770-237-1723

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

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	06/06/2008

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