Healthcare Provider Details

I. General information

NPI: 1174904304
Provider Name (Legal Business Name): SEBAN LIU D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2015
Last Update Date: 07/30/2021
Certification Date: 07/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N WALL ST
KANKAKEE IL
60901-2942
US

IV. Provider business mailing address

500 N WALL ST
KANKAKEE IL
60901-2942
US

V. Phone/Fax

Practice location:
  • Phone: 844-404-4787
  • Fax: 815-936-3242
Mailing address:
  • Phone: 844-404-4787
  • Fax: 815-936-3243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036157303
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: