=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437134673
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLIE M KOBLENTZ MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2005
-----------------------------------------------------
Last Update Date | 12/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2351 E 22ND ST PSYCHIATRY DEPT
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44115-3111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-363-2538
-----------------------------------------------------
Fax | 216-694-4604
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | METROHEALTH SYSTEM 4229 PEARL RD ATTN:PFS-LGREENHILL
-----------------------------------------------------
City | CLEVELAND
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44109-1998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-957-2442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 35081900
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------