Healthcare Provider Details

I. General information

NPI: 1649698135
Provider Name (Legal Business Name): RONALD MARK LIEBMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 08/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 HOGBACK RD SUITE 1
ANN ARBOR MI
48105
US

IV. Provider business mailing address

22350 WORCESTER DR.
NOVI MI
48374
US

V. Phone/Fax

Practice location:
  • Phone: 734-786-2300
  • Fax: 734-786-4915
Mailing address:
  • Phone: 516-458-6353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number5101021197
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: