Provider Demographics
NPI:1801806351
Name:NIEDERMAN, LEO G (MD)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:G
Last Name:NIEDERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 W CONGRESS PKWY
Mailing Address - Street 2:770 JONES
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3833
Mailing Address - Country:US
Mailing Address - Phone:312-942-1501
Mailing Address - Fax:312-563-4159
Practice Address - Street 1:1653 W CONGRESS PKWY
Practice Address - Street 2:770 JONES
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3244
Practice Address - Country:US
Practice Address - Phone:312-942-1501
Practice Address - Fax:312-563-4159
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036061069208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
C42705Medicare UPIN
L52494Medicare ID - Type Unspecified