Basic Information
| Provider Information | |||||||||
| NPI: | 1255372900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEADBETTER | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322857 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322857 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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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 | 207R00000X | 36604 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0402550 | 01 | MN | MEDICA # | OTHER | 0402551 | 01 | MN | MEDICA # | OTHER | 110073027 | 01 | MN | RR MEDICARE # | OTHER | 167284 | 01 | MN | UCARE # | OTHER | 0403068 | 01 | MN | MEDICA # | OTHER | 2M786LE | 01 | MN | MNBS # | OTHER | 899037 | 01 | MN | AMERICA'S PPO/ARAZ # | OTHER | 692765300 | 05 | MN | MEDICAID | 11721 | 01 | MN | NDBS # | OTHER | 8F747LE | 01 | MN | MNBS # | OTHER | DA9041015687 | 01 | MN | PREFERRED ONE # | OTHER | 8F746LE | 01 | MN | MNBS # | OTHER | HP19540 | 01 | MN | HEALTHPARTNERS # | OTHER | MN100005 | 01 | MN | LHS/BANNERHEALTH # | OTHER |