Provider Demographics
NPI:1093797326
Name:QUALLICH, LEONARD G III (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:G
Last Name:QUALLICH
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4600 INVESTMENT DR
Mailing Address - Street 2:STE 380
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098
Mailing Address - Country:US
Mailing Address - Phone:248-267-5025
Mailing Address - Fax:248-267-5026
Practice Address - Street 1:4600 INVESTMENT DR
Practice Address - Street 2:STE 380
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098
Practice Address - Country:US
Practice Address - Phone:248-267-5025
Practice Address - Fax:248-267-5026
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301067700207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H55462Medicare UPIN
M00540008Medicare ID - Type Unspecified