MEDICARE: DR. BRUCE W LESLIE M.D.

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	207R00000X	Internal Medicine Physician	14236	WV

General Provider Information

NPI Number	:	1457455958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE W LESLIE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:
City	:	PETERSBURG
State	:	WV
Zip	:	26847-0158
Country	:	US
Telephone Number	:	304-257-2527
Fax Number	:

Provider Business Practice Location Address
First Line	:	GRANT MEMORIAL DRIVE
Second Line	:	PIDC BUILDING - SUITE 102
City	:	PETERSBURG
State	:	WV
Zip	:	26847-1716
Country	:	US
Telephone Number	:	304-257-2527
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	03/11/2010

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