Healthcare Provider Details

I. General information

NPI: 1538223466
Provider Name (Legal Business Name): DELAWARE INTERVENTIONAL SPINE ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1673 S STATE ST SUITE B
DOVER DE
19901-5148
US

IV. Provider business mailing address

1673 S STATE ST SUITE B
DOVER DE
19901-5148
US

V. Phone/Fax

Practice location:
  • Phone: 302-674-8444
  • Fax: 302-674-8588
Mailing address:
  • Phone: 302-674-8444
  • Fax: 302-674-8588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberC20004708
License Number StateDE

VIII. Authorized Official

Name: DR. RONALD MICHAEL LIEBERMAN
Title or Position: DOCTOR
Credential: D.O.
Phone: 302-674-8444