Healthcare Provider Details

I. General information

NPI: 1669980504
Provider Name (Legal Business Name): LIBERTY PARK ANESTHESIA SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2018
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1940 STONEGATE DR STE 30
VESTAVIA HLS AL
35242
US

IV. Provider business mailing address

1940 STONEGATE DR STE 30
VESTAVIA HLS AL
35242-2540
US

V. Phone/Fax

Practice location:
  • Phone: 205-977-9876
  • Fax: 205-977-9976
Mailing address:
  • Phone: 205-977-9876
  • Fax: 205-977-9976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number StateAL

VIII. Authorized Official

Name: CHRISTOPHER B HARMON
Title or Position: OWNER
Credential: MD
Phone: 205-977-9876