Provider Demographics
NPI:1134133416
Name:ADVANCED MEDICAL CENTER LLC
Entity Type:Organization
Organization Name:ADVANCED MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEACH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-566-7676
Mailing Address - Street 1:1250 PINE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34108-8913
Mailing Address - Country:US
Mailing Address - Phone:239-566-7676
Mailing Address - Fax:239-254-3105
Practice Address - Street 1:1250 PINE RIDGE RD
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-8913
Practice Address - Country:US
Practice Address - Phone:239-566-7676
Practice Address - Fax:239-254-3105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42024207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL77872Medicare ID - Type Unspecified