1437473089 NPI number — ABC PEDIATRIC THERAPY

Table of content: WILLIAM NATHAN LISBERG MD (NPI 1003816075)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437473089 NPI number — ABC PEDIATRIC THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ABC PEDIATRIC THERAPY
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:
1437473089
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3308 OASIS SPRINGS RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIO RANCHO
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87144-2579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-980-3051
Provider Business Mailing Address Fax Number:
505-892-7359

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3308 OASIS SPRINGS RD NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIO RANCHO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87144-2579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-891-2590
Provider Business Practice Location Address Fax Number:
505-892-7359
Provider Enumeration Date:
03/24/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HERRERA
Authorized Official First Name:
VICTORIA
Authorized Official Middle Name:
MARGARET
Authorized Official Title or Position:
SPEECH PATHOLOGIST
Authorized Official Telephone Number:
505-891-2590

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  4246 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 78682908 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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