Provider Demographics
NPI:1831253939
Name:LORI LEIPOLD DO
Entity type:Organization
Organization Name:LORI LEIPOLD DO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIPOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:708-460-5404
Mailing Address - Street 1:15300 WEST AVE
Mailing Address - Street 2:205
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4600
Mailing Address - Country:US
Mailing Address - Phone:708-460-5404
Mailing Address - Fax:
Practice Address - Street 1:15300 WEST AVE
Practice Address - Street 2:205
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-4600
Practice Address - Country:US
Practice Address - Phone:708-460-5404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL202665Medicare ID - Type Unspecified