Provider Demographics
NPI:1083610406
Name:LEACH, JEFFREY L (CRNA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:LEACH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 MAYAPPLE DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-2452
Mailing Address - Country:US
Mailing Address - Phone:330-315-8398
Mailing Address - Fax:
Practice Address - Street 1:832 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-2208
Practice Address - Country:US
Practice Address - Phone:330-682-3010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-136249207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0918556Medicaid
OH000000024058OtherANTHEM PIN
OH000000024058OtherANTHEM PIN