=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871687061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE J LEACH D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 10/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20270 MIDDLEBELT RD SUITE 10
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-476-1210
-----------------------------------------------------
Fax | 248-476-9280
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20270 MIDDLEBELT RD SUITE 10
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48152-2000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-476-1210
-----------------------------------------------------
Fax | 248-476-9280
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 5101006363
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207U00000X
-----------------------------------------------------
Taxonomy Name | Nuclear Medicine Physician
-----------------------------------------------------
License Number | 5101006363
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------