Healthcare Provider Details

I. General information

NPI: 1477673713
Provider Name (Legal Business Name): MICHAEL THOMAS LIEBERTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 HUDSON AVE SURGICAL SPECIALISTS OF GLENS FALLS HOSPITAL
GLENS FALLS NY
12801-4448
US

IV. Provider business mailing address

100 PARK STREET GLENS FALLS HOSPITAL - CREDENTIALING
GLENS FALLS NY
12801-4413
US

V. Phone/Fax

Practice location:
  • Phone: 518-926-5600
  • Fax: 518-926-5605
Mailing address:
  • Phone: 518-926-5924
  • Fax: 518-926-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number225441
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: