Basic Information
| Provider Information | |||||||||
| NPI: | 1003889866 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEIDNER | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 PHILLIPS BEACH AVENUE | ||||||||
| Address2: | |||||||||
| City: | SWAMPSCOTT | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7815991915 | ||||||||
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| Practice Location | |||||||||
| Address1: | 55 HIGHLAND AVUENE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SALEM | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9787456601 | ||||||||
| FaxNumber: | 9787444872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 08/01/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 41165 | MA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 0012295 | 01 | MA | NEIGHBORHOOD HEALTH | OTHER | 041165 | 01 | MA | TUFTS | OTHER | D25068 | 01 | MA | BLUE SHIELD | OTHER | 19337 | 01 | MA | HARVARD PILGRIM | OTHER | 1000022 | 01 | MA | UNITED HEALTH CARE | OTHER | 2084278 | 01 | MA | AETNA | OTHER | 2054434 | 05 | MA | MEDICAID | 36228 | 01 | MA | FALLON | OTHER |