Healthcare Provider Details

I. General information

NPI: 1518023498
Provider Name (Legal Business Name): BERTRAM SIDNEY LIEBROSS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 GREENLEAF HL
GREAT NECK NY
11023-1809
US

IV. Provider business mailing address

55 GREENLEAF HL
GREAT NECK NY
11023-1809
US

V. Phone/Fax

Practice location:
  • Phone: 516-829-3794
  • Fax: 516-829-3794
Mailing address:
  • Phone: 516-829-3794
  • Fax: 516-829-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number101408
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: