1770677809 NPI number — MR. ETHAN JOHN LIEBLER MSPT

Table of content: MR. ETHAN JOHN LIEBLER MSPT (NPI 1770677809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770677809 NPI number — MR. ETHAN JOHN LIEBLER MSPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIEBLER
Provider First Name:
ETHAN
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSPT
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:
1770677809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
56 HEMLOCK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGDALE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11735-2929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-852-5429
Provider Business Mailing Address Fax Number:
516-293-3829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NORTHERN BLVD
Provider Second Line Business Practice Location Address:
117
Provider Business Practice Location Address City Name:
GREAT NECK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11021-5200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-478-0014
Provider Business Practice Location Address Fax Number:
516-487-3989
Provider Enumeration Date:
10/03/2006

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: 225100000X , with the licence number:  22696 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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