Healthcare Provider Details

I. General information

NPI: 1619259280
Provider Name (Legal Business Name): LEAH BALDAUFF MS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 02/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1 WESTBROOK CORPORATE CTR STE 240
WESTCHESTER IL
60154-5745
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5000
  • Fax:
Mailing address:
  • Phone: 630-710-0124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.004062
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: