Provider Demographics
NPI:1417268764
Name:BRUCE C LEITKAM DO PC
Entity Type:Organization
Organization Name:BRUCE C LEITKAM DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNE
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:LEITKAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:810-735-1231
Mailing Address - Street 1:490 W BROAD ST
Mailing Address - Street 2:PO BOX 605
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8862
Mailing Address - Country:US
Mailing Address - Phone:810-735-1231
Mailing Address - Fax:810-735-1092
Practice Address - Street 1:490 W BROAD ST
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8862
Practice Address - Country:US
Practice Address - Phone:810-735-1231
Practice Address - Fax:810-735-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBL006591208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1552457Medicaid
MI5251061OtherBCBS
MIE25562Medicare UPIN
MI5253934Medicare PIN