Organization
LEESTMA MEDICAL CLINIC, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ERIC J LEESTMA D.O. (PRESIDENT)
(219) 987-7750
Entity
Organization
Contact information
Practice address
519 N HALLECK ST, DEMOTTE, IN 46310-9553
(219) 987-7750
(219) 987-5750
Mailing address
PO BOX 850, DEMOTTE, IN 46310-0850
(219) 987-7750
(219) 987-5750
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
02000641A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000084931
ANTHEM BCBS
IN
01
—
080088241
RAILROAD MEDICARE
—
05
—
100209310A
—
IN
Enumeration date
02/02/2010
Last updated
05/04/2010
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