Provider Demographics
NPI:1720014053
Name:LEIDER, HOLLY A (MD)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:A
Last Name:LEIDER
Suffix:
Gender:F
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3003 W GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2042
Practice Address - Country:US
Practice Address - Phone:414-352-3100
Practice Address - Fax:414-247-4597
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40183207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00679661OtherRR MEDICARE
WI32626600Medicaid
WI46236-0050Medicare PIN
WIH11683Medicare UPIN
WI32626600Medicaid