1336488501 NPI number — LIBERTY SURGICAL ASSOCIATES PLLC

Table of content: (NPI 1336488501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336488501 NPI number — LIBERTY SURGICAL ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY SURGICAL ASSOCIATES PLLC
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:
1336488501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 202428
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-224-2292
Provider Business Mailing Address Fax Number:
866-279-9993

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
306 E. RANDOL MILL RD.
Provider Second Line Business Practice Location Address:
SUITE136
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-224-2292
Provider Business Practice Location Address Fax Number:
866-279-9993
Provider Enumeration Date:
02/08/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RAY
Authorized Official First Name:
DUSTIN
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
202-271-0205

Provider Taxonomy Codes

  • Taxonomy code: 207XS0106X , with the licence number:  N6605 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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