Provider Demographics
NPI:1871696229
Name:LEIFHEIT, JOEL S (MD)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:S
Last Name:LEIFHEIT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:920 WEST ST
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354
Mailing Address - Country:US
Mailing Address - Phone:815-223-4273
Mailing Address - Fax:815-223-4328
Practice Address - Street 1:920 WEST ST
Practice Address - Street 2:SUITE 111
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354
Practice Address - Country:US
Practice Address - Phone:815-223-4273
Practice Address - Fax:815-223-4328
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093954208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG35403Medicare UPIN
ILL83797Medicare ID - Type Unspecified