Healthcare Provider Details

I. General information

NPI: 1679777908
Provider Name (Legal Business Name): LIBERTY MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 NE 96TH ST
LIBERTY MO
64068-1348
US

IV. Provider business mailing address

1504 NE 96TH ST
LIBERTY MO
64068-1348
US

V. Phone/Fax

Practice location:
  • Phone: 816-415-2233
  • Fax: 816-415-2218
Mailing address:
  • Phone: 816-415-2233
  • Fax: 816-415-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2000146367
License Number StateMO

VIII. Authorized Official

Name: RODNEY JAMES MALISOS
Title or Position: PRESIDENT
Credential: MD
Phone: 816-415-2233