Healthcare Provider Details

I. General information

NPI: 1255522611
Provider Name (Legal Business Name): MERVIN NIGEL LEADER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2007
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 COUNTY ROAD 2150 E
FAIRFIELD IL
62837-2823
US

IV. Provider business mailing address

303 NW 11TH ST
FAIRFIELD IL
62837-1203
US

V. Phone/Fax

Practice location:
  • Phone: 479-259-8855
  • Fax: 870-364-9774
Mailing address:
  • Phone: 618-842-4617
  • Fax: 618-847-8387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberE-5515
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036163562
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: