Healthcare Provider Details

I. General information

NPI: 1508110198
Provider Name (Legal Business Name): LESLIE STANISLAUS ANEWENAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2012
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 E LAKE SHORE DR
DECATUR IL
62521-3809
US

IV. Provider business mailing address

84-2 FERNE BLVD
DREXEL HILL PA
19026-5510
US

V. Phone/Fax

Practice location:
  • Phone: 217-329-1000
  • Fax:
Mailing address:
  • Phone: 302-983-5330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number79450
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number78387
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036149330
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: