Provider Demographics
NPI:1831534445
Name:LEIB, AMY
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LEIB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 S NEW MIDDLETOWN RD STE 203
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5255
Mailing Address - Country:US
Mailing Address - Phone:610-566-7300
Mailing Address - Fax:
Practice Address - Street 1:4 INDUSTRIAL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PAOLI
Practice Address - State:PA
Practice Address - Zip Code:19301-1605
Practice Address - Country:US
Practice Address - Phone:610-647-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT203560390200000X
VA0116026680207N00000X
PAMD460475207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program