Healthcare Provider Details

I. General information

NPI: 1083877088
Provider Name (Legal Business Name): KRISTEN LEADBETTER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 9TH ST STE 4W16
SPRINGFIELD IL
62702-5303
US

IV. Provider business mailing address

PO BOX 19676
SPRINGFIELD IL
62794-9676
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax: 217-757-6844
Mailing address:
  • Phone: 217-545-8000
  • Fax: 217-757-6844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036-134761
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-134761
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: