Provider Demographics
NPI:1922023936
Name:LEACH, RACHELLE M (MD)
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:M
Last Name:LEACH
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 8882
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0882
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:211 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1915
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-106830207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008232053OtherBLUECROSS BLUE SHIELD
IL08232205OtherBLUE CROSS BLUE SHIELD
ILP00339436OtherRAILROAD MEDICARE
IL036106830Medicaid
IL06032182OtherBLUE CROSS BLUE SHIELD
IL08232204OtherBLUE CROSS BLUE SHIELD
ILK28767Medicare PIN
IL036106830Medicaid
IL0008232053OtherBLUECROSS BLUE SHIELD
ILK29107Medicare PIN