Provider Demographics
NPI:1629014022
Name:EDGCOMB, LESLIE PAUL (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:PAUL
Last Name:EDGCOMB
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 1:5668 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2464
Mailing Address - Country:US
Mailing Address - Phone:815-229-7580
Mailing Address - Fax:
Practice Address - Street 1:5668 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2464
Practice Address - Country:US
Practice Address - Phone:815-229-7580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360721042086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036072104Medicaid
WI30696600Medicaid
020017328OtherRAILROAD MEDICARE
747120Medicare ID - Type Unspecified
IL036072104Medicaid