Provider Demographics
NPI:1093827685
Name:LEISEBERG, KEVIN ALAN (MS, PT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:ALAN
Last Name:LEISEBERG
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:
Practice Address - Street 1:300 S STATE ST
Practice Address - Street 2:
Practice Address - City:MARENGO
Practice Address - State:IL
Practice Address - Zip Code:60152-3532
Practice Address - Country:US
Practice Address - Phone:815-568-4550
Practice Address - Fax:815-568-5071
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-011208225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0604410001OtherDMERC
ILP00350919OtherRAILROAD MEDICARE NUMBER
ILP01119498OtherRAILROAD MEDICARE
ILIL6237003OtherMEDICARE
ILIL6238003OtherMEDICARE
ILIL6697010OtherMEDICARE
ILIL6238003OtherMEDICARE
ILK25165Medicare ID - Type Unspecified
ILIL6238003OtherMEDICARE