MEDICARE: DR. JULIAN LIEB MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	CT16254	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	010016254CT01	OTHER	CT	ANTHEM BCBS

General Provider Information

NPI Number	:	1306847199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JULIAN LIEB MD

Provider Business Mailing Address
First Line	:	22 RIMMON RD
Second Line	:
City	:	WOODBRIDGE
State	:	CT
Zip	:	06525-2002
Country	:	US
Telephone Number	:	203-397-1226
Fax Number	:	203-397-1246

Provider Business Practice Location Address
First Line	:	22 RIMMON RD
Second Line	:
City	:	WOODBRIDGE
State	:	CT
Zip	:	06525-2002
Country	:	US
Telephone Number	:	203-397-1226
Fax Number	:	203-397-1246

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	07/08/2007

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