MEDICARE: LESLIE A BAIN MD MEDICAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	A24274	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A24274A	OTHER		MEDICARE ID

General Provider Information

NPI Number	:	1316255680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LESLIE A BAIN MD MEDICAL CORPORATION

Provider Business Mailing Address
First Line	:	1441 AVOCADO AVE
Second Line	:	SUITE 706
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7721
Country	:	US
Telephone Number	:	949-720-9170
Fax Number	:	949-720-0755

Provider Business Practice Location Address
First Line	:	1441 AVOCADO AVE
Second Line	:	SUITE 706
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7721
Country	:	US
Telephone Number	:	949-720-9170
Fax Number	:	949-720-0755

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. LESLIE BAIN
Credential	:	MD
Telephone Number	:	949-720-9170

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	09/20/2010

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