Healthcare Provider Details

I. General information

NPI: 1952469579
Provider Name (Legal Business Name): JG LEIJA MD FACA LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W NORTH AVE SUITE 310
MELROSE PARK IL
60160-1634
US

IV. Provider business mailing address

675 W NORTH AVE SUITE 310
MELROSE PARK IL
60160-1634
US

V. Phone/Fax

Practice location:
  • Phone: 708-450-5054
  • Fax: 708-450-9088
Mailing address:
  • Phone: 708-450-5054
  • Fax: 708-450-9088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number03635559
License Number StateIL

VIII. Authorized Official

Name: DR. JOSEPH G LEIJA
Title or Position: PRESIDENT OWNER
Credential: MD
Phone: 708-450-5054