Provider Demographics
NPI:1194795187
Name:LESLIE G MACAULEY MD PC
Entity type:Organization
Organization Name:LESLIE G MACAULEY MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:GREENE
Authorized Official - Last Name:MACAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-333-7115
Mailing Address - Street 1:PO BOX 428
Mailing Address - Street 2:611 COURT STREET
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-0428
Mailing Address - Country:US
Mailing Address - Phone:877-595-1090
Mailing Address - Fax:989-345-5803
Practice Address - Street 1:4970 NORTHWIND DR
Practice Address - Street 2:SUITE 220
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5080
Practice Address - Country:US
Practice Address - Phone:517-333-7115
Practice Address - Fax:517-333-6771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010622992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4455930Medicaid
G37550Medicare UPIN
MI0P15900Medicare ID - Type Unspecified