1639166853 NPI number — R SCOTT LIEBL MD

Table of content: R SCOTT LIEBL MD (NPI 1639166853)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639166853 NPI number — R SCOTT LIEBL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIEBL
Provider First Name:
R
Provider Middle Name:
SCOTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1639166853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
835 S MAIN ST
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
OCONTO FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54154-1241
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-846-8424
Provider Business Mailing Address Fax Number:
920-846-2073

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
OCONTO FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54154-1241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-846-8424
Provider Business Practice Location Address Fax Number:
920-846-2073
Provider Enumeration Date:
10/03/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  21763020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 11014110 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1851477913 . This is a "NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 390848401050 . This is a "BXBS" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 30189000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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