Provider Demographics
NPI:1982637179
Name:LEAVEY, MARC I (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:I
Last Name:LEAVEY
Suffix:
Gender:M
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 62026
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1205 YORK RD
Practice Address - Street 2:
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6210
Practice Address - Country:US
Practice Address - Phone:410-825-4979
Practice Address - Fax:410-296-3630
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0017041207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD147451100Medicaid
MDS190 / 0011OtherBLUE CHOICE
MD493648OtherAETNA
MDKF68 / 416714-01OtherBC/BS OF MD
MD147451100Medicaid
MDKF68 / 416714-01OtherBC/BS OF MD