MEDICARE: MICHAEL CARTER LEATH 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	207R00000X	Internal Medicine Physician	E2672	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	110219847	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0004357854	OTHER	TX	AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0043GG	OTHER	TX	BLUE CROSS

General Provider Information

NPI Number	:	1831197524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL CARTER LEATH MD

Provider Business Mailing Address
First Line	:	PO BOX 2506
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75606
Country	:	US
Telephone Number	:	903-235-4232
Fax Number	:	903-663-0551

Provider Business Practice Location Address
First Line	:	7470 STATE HWY 154
Second Line	:	OAK HAVEN RECOVERY CENTER
City	:	MARSHALL
State	:	TX
Zip	:	75670
Country	:	US
Telephone Number	:	903-938-5149
Fax Number	:	903-753-9141

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	10/07/2010

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