1174502454 NPI number — DR. OLIVIA LIAO MD

Table of content: DR. OLIVIA LIAO MD (NPI 1174502454)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174502454 NPI number — DR. OLIVIA LIAO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIAO
Provider First Name:
OLIVIA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174502454
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21 WORTHEN RD
Provider Second Line Business Mailing Address:
ATTN: AMY KILPATRICK
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02421-4835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-862-1620
Provider Business Mailing Address Fax Number:
781-863-9416

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 WORTHEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02421-4835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-862-1620
Provider Business Practice Location Address Fax Number:
781-863-9416
Provider Enumeration Date:
01/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  75542 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NX2629 , issued by the state of ( MA ) . This identifiers is of the category "MEDICARE PIN".
  • Identifier: G36555 , issued by the state of ( MA ) . This identifiers is of the category "MEDICARE UPIN".
  • Identifier: 3173844 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".