Healthcare Provider Details

I. General information

NPI: 1174582951
Provider Name (Legal Business Name): KENNETH V LIEBERMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 09/30/2022
Certification Date: 09/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE HUMC - PEDIATRIC CENTER
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-8228
  • Fax: 551-996-5397
Mailing address:
  • Phone: 551-996-8228
  • Fax: 551-996-5397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number25MA07270700
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00634193 046
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier051590DHK
Identifier TypeOTHER
Identifier State
Identifier IssuerPIN
# 3
Identifier0923702
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: