Provider Demographics
NPI:1548235864
Name:LEISCHNER, MATTHEW P (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:P
Last Name:LEISCHNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 S FIRST AVE
Mailing Address - Street 2:(LUH - NORTH ENT., RM 2601)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153
Mailing Address - Country:US
Mailing Address - Phone:708-327-9152
Mailing Address - Fax:708-216-0814
Practice Address - Street 1:2160 S FIRST AVE
Practice Address - Street 2:(LUH - NORTH ENT., RM 2601)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153
Practice Address - Country:US
Practice Address - Phone:708-216-5118
Practice Address - Fax:708-216-0814
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36104232208000000X
IL036104232208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36104232Medicaid
IL36104232Medicaid
H65036Medicare UPIN