Provider Demographics
NPI:1063402048
Name:LEONARD, MARY BETH (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:LEONARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3245 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3474
Mailing Address - Country:US
Mailing Address - Phone:708-484-0621
Mailing Address - Fax:708-484-0250
Practice Address - Street 1:3245 GROVE AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3474
Practice Address - Country:US
Practice Address - Phone:708-484-0621
Practice Address - Fax:708-484-0250
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2011-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-079983208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
01619787OtherBCBSIL GROUP NUMBER
IL036079983Medicaid
IL020040376Medicare PIN
ILA49101Medicare UPIN
IL036079983Medicaid
ILL66791Medicare PIN
ILCI2940Medicare PIN
ILK22627Medicare PIN
IL212474Medicare PIN