=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891720827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEVIN L LEEN MD E ALLAN SPEIDELL MD ASSOC IN INTERNAL MED PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 03/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 65 EAST NORTHFIELD ROAD
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-992-6487
-----------------------------------------------------
Fax | 973-992-7040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 65 EAST NORTHFIELD ROAD
-----------------------------------------------------
City | LIVINGSTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-992-6487
-----------------------------------------------------
Fax | 973-992-7040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | KEVIN LAURI LEEN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-992-6487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 25MA01924700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 25MA01920400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------