Healthcare Provider Details

I. General information

NPI: 1679513543
Provider Name (Legal Business Name): RANDY ALAN LIEBERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 SAINT ANTOINE ST STE 7B
DETROIT MI
48201-2153
US

IV. Provider business mailing address

400 MACK AVE
DETROIT MI
48201-2136
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-0233
  • Fax: 313-993-0295
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301074561
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number4301074561
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number4301074561
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: