Basic Information
| Provider Information | |||||||||
| NPI: | 1720515190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALBRIDGE | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MAWBY | ||||||||
| OtherFirstName: | LEAH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 400 HOBART ST | ||||||||
| Address2: | C/O HEATHER BYERS | ||||||||
| City: | CADILLAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496012331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318767807 | ||||||||
| FaxNumber: | 2318767176 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 MEDICAL CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | TRAVERSE CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496847823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2319358000 | ||||||||
| FaxNumber: | 2319358099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2017 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301112341 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 4301112341 | 01 | MI | LICENSE | OTHER |