Healthcare Provider Details

I. General information

NPI: 1992036651
Provider Name (Legal Business Name): SERENA MCCLAM LIEBENGOOD MD, MHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SERENA LYNN MCCLAM MD, MHS

II. Dates (important events)

Enumeration Date: 01/20/2010
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

PO BOX 64358
BALTIMORE MD
21264-4358
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-9446
  • Fax:
Mailing address:
  • Phone: 410-356-8186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number9557275
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberD70319
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: