Provider Demographics
NPI:1962661793
Name:LEITCH, SALLY S (MD)
Entity Type:Individual
Prefix:DR
First Name:SALLY
Middle Name:S
Last Name:LEITCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:10705 TOWN SQUARE DR NE
Practice Address - Street 2:SUITE 100
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-8184
Practice Address - Country:US
Practice Address - Phone:763-236-5400
Practice Address - Fax:763-236-5350
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN50899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080020779Medicare PIN