Healthcare Provider Details

I. General information

NPI: 1184903593
Provider Name (Legal Business Name): MICAH J LIEBERMAN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13642 RIVERWAY DR UNIT C
CHESTERFIELD MO
63017-2656
US

IV. Provider business mailing address

13642 RIVERWAY DR UNIT C
CHESTERFIELD MO
63017-2656
US

V. Phone/Fax

Practice location:
  • Phone: 908-938-8323
  • Fax:
Mailing address:
  • Phone: 908-938-8323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2011026323
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number38MC00695400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: