Healthcare Provider Details

I. General information

NPI: 1356723944
Provider Name (Legal Business Name): PATRICK LIEBEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 N CURTIS RD STE 415
BOISE ID
83706-1334
US

IV. Provider business mailing address

3340 E GOLDSTONE DR
MERIDIAN ID
83642-1026
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-2600
  • Fax: 208-302-2625
Mailing address:
  • Phone: 208-302-9342
  • Fax: 208-367-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberM-16663
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR3837
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number53908
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: