Healthcare Provider Details

I. General information

NPI: 1497375349
Provider Name (Legal Business Name): MOLLY BRIANNA LEAVITT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 10/12/2023
Certification Date: 10/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3249 OAK PARK AVE
BERWYN IL
60402-3429
US

IV. Provider business mailing address

180 HARVESTER DR STE 110
BURR RIDGE IL
60527-6686
US

V. Phone/Fax

Practice location:
  • Phone: 708-783-2226
  • Fax:
Mailing address:
  • Phone: 773-702-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125076067
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036164207
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: