Provider Demographics
NPI:1992756456
Name:LEIBOLD, THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:
Last Name:LEIBOLD
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 1:1903 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-5200
Mailing Address - Country:US
Mailing Address - Phone:269-387-3290
Mailing Address - Fax:
Practice Address - Street 1:1903 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-5200
Practice Address - Country:US
Practice Address - Phone:269-387-3290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301048147207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417961137OtherBCBSM - BMH
MI521519710Medicaid
0C94735OtherBCBS
MI1770597494OtherBCBSM - BVH
MI1992756456Medicaid
A78230Medicare UPIN
MI521519710Medicaid
MI0M22440021Medicare PIN
MIC96065047 - BVHMedicare PIN