Healthcare Provider Details

I. General information

NPI: 1912995762
Provider Name (Legal Business Name): JOHN A LIEBERMAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 N CAMPUS RIDGE DR SUITE B2200
MIDLAND MI
48640-6112
US

IV. Provider business mailing address

4401 N CAMPUS RIDGE DR SUITE B2200
MIDLAND MI
48640-6112
US

V. Phone/Fax

Practice location:
  • Phone: 989-837-9400
  • Fax:
Mailing address:
  • Phone: 989-837-9400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number5315016828
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: