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General NPI Number Information
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NPI Number | 1093172132
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Entity Type | Individual
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Provider Name | KENNETH C LEEBERG CRNA
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Gender | Male
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Dates
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Enumeration Date | 01/20/2016
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 19624 GOVERNORS HWY
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City | FLOSSMOOR
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State | IL
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Zip | 60422-2077
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Country | US
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Telephone | 708-798-5838
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Fax | 708-798-5865
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Provider Business Mailing Address
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Address Line | 23654 SPRINGS CT UNIT 119
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City | PLAINFIELD
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State | IL
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Zip | 60585-2243
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Country | US
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Telephone | 630-567-2132
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 209013780
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 041395579
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License Number State | IL
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