Healthcare Provider Details

I. General information

NPI: 1689856759
Provider Name (Legal Business Name): LIBERTY PULMONARY CRITICAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 11/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 GRAND ST
JERSEY CITY NJ
07302-4321
US

IV. Provider business mailing address

PO BOX 1557
LIVINGSTON NJ
07039-7157
US

V. Phone/Fax

Practice location:
  • Phone: 201-795-9155
  • Fax:
Mailing address:
  • Phone: 973-202-6120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. RAO MIKKILINENI
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 201-795-9155