Provider Demographics
NPI:1629151352
Name:BOLER, LEO (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:BOLER
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 1:3800 W MADISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60624-2334
Mailing Address - Country:US
Mailing Address - Phone:773-826-6600
Mailing Address - Fax:773-826-1407
Practice Address - Street 1:3800 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60624-2334
Practice Address - Country:US
Practice Address - Phone:773-826-6600
Practice Address - Fax:773-826-1407
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-067272207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C43307Medicare UPIN
367830Medicare PIN