Provider Demographics
NPI:1538246863
Name:DRS PAUL AND SHIRLEY LEADEM PA INC
Entity type:Organization
Organization Name:DRS PAUL AND SHIRLEY LEADEM PA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEADEM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:904-829-6591
Mailing Address - Street 1:1740 TREE BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5774
Mailing Address - Country:US
Mailing Address - Phone:904-829-6591
Mailing Address - Fax:
Practice Address - Street 1:1740 TREE BOULEVARD
Practice Address - Street 2:SUITE 112
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5774
Practice Address - Country:US
Practice Address - Phone:904-829-6591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74622OtherBC/BS FLORIDA
FL270529000Medicaid
FL4049277OtherAETNA GROUP NUMBER