Healthcare Provider Details

I. General information

NPI: 1285294348
Provider Name (Legal Business Name): CARL LIEBE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 HAMLINE ST
GRAND FORKS ND
58203-2819
US

IV. Provider business mailing address

725 HAMLINE ST
GRAND FORKS ND
58203-2819
US

V. Phone/Fax

Practice location:
  • Phone: 701-780-6810
  • Fax: 704-780-4391
Mailing address:
  • Phone: 701-780-6810
  • Fax: 704-780-4391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRL15809
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: