Healthcare Provider Details

I. General information

NPI: 1639375140
Provider Name (Legal Business Name): BENJAMIN WILLIAM LEACOCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BENJAMIN WILLIAM LEACOCK M.D.

II. Dates (important events)

Enumeration Date: 06/22/2007
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HEALTH CARE DR
GREENVILLE IL
62246-1154
US

IV. Provider business mailing address

PO BOX 912215
DENVER CO
80291-2215
US

V. Phone/Fax

Practice location:
  • Phone: 618-664-1230
  • Fax:
Mailing address:
  • Phone: 303-306-7101
  • Fax: 303-306-7753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number141051
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDR.0056078
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number01081797A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2010003231
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036148647
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD61595673
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: