Provider Demographics
NPI:1992744973
Name:PEDELL, LEON (MD)
Entity type:Individual
Prefix:DR
First Name:LEON
Middle Name:
Last Name:PEDELL
Suffix:
Gender:M
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:PO BOX 8225
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-8225
Mailing Address - Country:US
Mailing Address - Phone:248-618-6260
Mailing Address - Fax:284-618-6260
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-618-6260
Practice Address - Fax:284-618-6260
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILP036862207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2097821Medicaid
MI1106348892OtherBLUE CROSS BLUE SHIELD MI
MIB44610Medicare UPIN
MI0634889Medicare ID - Type Unspecified