1629254271 NPI number — MARCIA A. LIBERATORE, MD PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629254271 NPI number — MARCIA A. LIBERATORE, MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARCIA A. LIBERATORE, MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1629254271
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PMB 191
Provider Second Line Business Mailing Address:
922 NW CIRCLE BLVD, STE 160
Provider Business Mailing Address City Name:
CORVALLIS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97330-1410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-753-1172
Provider Business Mailing Address Fax Number:
541-752-9935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
917 NW GRANT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORVALLIS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97330-4570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-753-1172
Provider Business Practice Location Address Fax Number:
541-752-9935
Provider Enumeration Date:
01/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LIBERATORE
Authorized Official First Name:
MARCIA
Authorized Official Middle Name:
ANTOINETTE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-753-1172

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  MD24224 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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