1497947410 NPI number — LIBERTY HEALTHCARE GROUP, LLC

Table of content: (NPI 1497947410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497947410 NPI number — LIBERTY HEALTHCARE GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY HEALTHCARE GROUP, LLC
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:
1497947410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2334 S 41ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-5502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-815-3122
Provider Business Mailing Address Fax Number:
910-815-3111

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 S KINGS DR
Provider Second Line Business Practice Location Address:
SUITE JJ
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28204-2932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-940-8389
Provider Business Practice Location Address Fax Number:
704-940-8598
Provider Enumeration Date:
08/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ZIZZAMIA
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
910-815-3122

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HC3694 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3407242 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007CH . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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