Healthcare Provider Details

I. General information

NPI: 1730550070
Provider Name (Legal Business Name): LEO TING MMS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 10/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7531 S STONY ISLAND AVE
CHICAGO IL
60649-3954
US

IV. Provider business mailing address

1536 N. CLAREMONT AVE. #GDN
CHICAGO IL
60622
US

V. Phone/Fax

Practice location:
  • Phone: 773-947-7500
  • Fax:
Mailing address:
  • Phone: 651-927-9133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005686
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: