Healthcare Provider Details

I. General information

NPI: 1063788818
Provider Name (Legal Business Name): JEFFREY LEIDER MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 AUGUSTA AVE
FT WRIGHT KY
41011-3603
US

IV. Provider business mailing address

1200 KIRTS BLVD SUITE 200
TROY MI
48084-4899
US

V. Phone/Fax

Practice location:
  • Phone: 248-528-1981
  • Fax: 248-528-2963
Mailing address:
  • Phone: 248-528-1981
  • Fax: 248-528-2963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY LEIDER
Title or Position: CLINICAL DIRECTOR
Credential: MD
Phone: 248-528-1981