Healthcare Provider Details

I. General information

NPI: 1861490559
Provider Name (Legal Business Name): ROBERT GRIERSON LECKIE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 04/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E HASKELL ST
WINNEMUCCA NV
89445-3247
US

IV. Provider business mailing address

PO BOX 32936
KNOXVILLE TN
37930-2936
US

V. Phone/Fax

Practice location:
  • Phone: 775-623-5222
  • Fax:
Mailing address:
  • Phone: 800-489-8531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number7705
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG86763
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: