Provider Demographics
NPI:1841414166
Name:THOMAS J. LEAVITT MD PC
Entity Type:Organization
Organization Name:THOMAS J. LEAVITT MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-255-7564
Mailing Address - Street 1:284 BUCK RUN
Mailing Address - Street 2:
Mailing Address - City:SAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83860
Mailing Address - Country:US
Mailing Address - Phone:208-255-7564
Mailing Address - Fax:208-255-7537
Practice Address - Street 1:284 BUCK RUN
Practice Address - Street 2:
Practice Address - City:SAGLE
Practice Address - State:ID
Practice Address - Zip Code:83860
Practice Address - Country:US
Practice Address - Phone:208-255-7564
Practice Address - Fax:208-255-7537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9379207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A38180Medicare UPIN
ID1366347Medicare PIN