Provider Demographics
NPI:1548369317
Name:LEAHY-AUER, JOANNE M (MD)
Entity type:Individual
Prefix:DR
First Name:JOANNE
Middle Name:M
Last Name:LEAHY-AUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RIVERSIDE DR STE 2400
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-5068
Mailing Address - Country:US
Mailing Address - Phone:815-935-4907
Mailing Address - Fax:815-935-1723
Practice Address - Street 1:300 RIVERSIDE DR STE 2400
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-5068
Practice Address - Country:US
Practice Address - Phone:815-935-4907
Practice Address - Fax:815-935-1723
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036075476208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036075476Medicaid
IL36075476Medicaid
ILE29977Medicare UPIN
IL36-3167726Medicare ID - Type UnspecifiedGROUP TAX ID#