Healthcare Provider Details

I. General information

NPI: 1629254271
Provider Name (Legal Business Name): MARCIA A. LIBERATORE, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 NW GRANT AVE
CORVALLIS OR
97330-4570
US

IV. Provider business mailing address

PMB 191 922 NW CIRCLE BLVD, STE 160
CORVALLIS OR
97330-1410
US

V. Phone/Fax

Practice location:
  • Phone: 541-753-1172
  • Fax: 541-752-9935
Mailing address:
  • Phone: 541-753-1172
  • Fax: 541-752-9935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberMD24224
License Number StateOR

VIII. Authorized Official

Name: DR. MARCIA ANTOINETTE LIBERATORE
Title or Position: OWNER
Credential: MD
Phone: 541-753-1172