Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | IL |
NPI | 1043248867 |
---|---|
Provider Name | Dr. Benjamin J Leak |
First Address | Bloomington, IL 61701-3514 |
Second Address | Bloomington, IL 61701-3514 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2006 |
Last Update Date | 13/09/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0723870001 | DME PROVIDER NUMBER (01) | IL |
5732045 | BC BS PROVIDER NUMBER (01) | IL |
I02495 | (02) | IL |
P00100008 | RAILROAD MEDICARE (01) | IL |