MEDICARE: FREDERICK E LEICKLY MD

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	207K00000X	Allergy & Immunology Physician	01042436A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	IN1125015	OTHER	IN	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679682710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FREDERICK E LEICKLY MD

Provider Business Mailing Address
First Line	:	DEPT. 453 PO BOX 1000
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38148-0001
Country	:	US
Telephone Number	:	828-575-2625
Fax Number	:	828-350-2174

Provider Business Practice Location Address
First Line	:	2665 FOX POINTE DR
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-3222
Country	:	US
Telephone Number	:	812-378-3131
Fax Number	:	812-379-9251

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	05/03/2022

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Directions to “ FREDERICK E LEICKLY MD” Practice Location

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