Provider Demographics
NPI:1457346322
Name:TAIBERG, LEO (MD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:
Last Name:TAIBERG
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 1:4724 WELLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5223
Mailing Address - Country:US
Mailing Address - Phone:847-804-1711
Mailing Address - Fax:
Practice Address - Street 1:801 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3204
Practice Address - Country:US
Practice Address - Phone:847-362-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.105481207RC0200X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105481Medicaid
ILP00165716OtherRAIL ROAD MEDICARE
IL01634713OtherBCBS PROVIDER ID
ILP00165716Medicare PIN
ILP00165716OtherRAIL ROAD MEDICARE
ILI18570Medicare UPIN
IL01634713OtherBCBS PROVIDER ID