MEDICARE: DR. LELAND M LAYCOB 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	208000000X	Pediatrics Physician	31890	MO

General Provider Information

NPI Number	:	1770559908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LELAND M LAYCOB MD

Provider Business Mailing Address
First Line	:	777 S NEW BALLAS RD
Second Line	:	SUITE 107-W
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8705
Country	:	US
Telephone Number	:	314-872-8752
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 S NEW BALLAS RD
Second Line	:	SUITE 107-W
City	:	SAINT LOUIS
State	:	MO
Zip	:	63141-8705
Country	:	US
Telephone Number	:	314-872-8752
Fax Number	:

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	05/16/2011

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