Provider Demographics
NPI:1497748933
Name:LEIBY, KRAIG WILLIAM (PTA)
Entity Type:Individual
Prefix:MR
First Name:KRAIG
Middle Name:WILLIAM
Last Name:LEIBY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 BROADCASTING RD
Mailing Address - Street 2:STE 201
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3220
Mailing Address - Country:US
Mailing Address - Phone:610-685-9600
Mailing Address - Fax:610-685-6700
Practice Address - Street 1:1350 BROADCASTING RD
Practice Address - Street 2:STE 201
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-3220
Practice Address - Country:US
Practice Address - Phone:610-685-9600
Practice Address - Fax:610-685-6700
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008902L208100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
076572TCSMedicare ID - Type Unspecified