Provider Demographics
NPI:1912023383
Name:CHICK, LELAND RUSSEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LELAND
Middle Name:RUSSEL
Last Name:CHICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:24 S 1100 E
Mailing Address - Street 2:STE 201
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1500
Mailing Address - Country:US
Mailing Address - Phone:801-322-1188
Mailing Address - Fax:801-363-1847
Practice Address - Street 1:1220 E 3900 S STE 4I
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1383
Practice Address - Country:US
Practice Address - Phone:801-322-1188
Practice Address - Fax:801-363-1847
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT89-180960-12052086S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005770301Medicare ID - Type Unspecified
UTA65293Medicare UPIN