Provider Demographics
NPI:1326227752
Name:KANE, LESLEE BERGUM (MD)
Entity type:Individual
Prefix:DR
First Name:LESLEE
Middle Name:BERGUM
Last Name:KANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LESLEE
Other - Middle Name:LYNN
Other - Last Name:BERGUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:206 ALASKA FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-7909
Mailing Address - Country:US
Mailing Address - Phone:406-414-3334
Mailing Address - Fax:
Practice Address - Street 1:206 ALASKA FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-7909
Practice Address - Country:US
Practice Address - Phone:406-414-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-26476207Q00000X
IN01066304A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine