1952618696 NPI number — LIBERTY STREET INTERNAL MEDICINE PC

Table of content: (NPI 1952618696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952618696 NPI number — LIBERTY STREET INTERNAL MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY STREET INTERNAL MEDICINE 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:
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:
1952618696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
765 LIBERTY ST
Provider Second Line Business Mailing Address:
SUITE 301
Provider Business Mailing Address City Name:
MEADVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16335-2566
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-336-3506
Provider Business Mailing Address Fax Number:
814-724-8343

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
765 LIBERTY ST
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335-2566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-333-1081
Provider Business Practice Location Address Fax Number:
814-724-8343
Provider Enumeration Date:
09/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
YEAGER
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
814-336-3506

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD440871 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD440871 . This is a "LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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