Healthcare Provider Details

I. General information

NPI: 1609086636
Provider Name (Legal Business Name): CHENGYU LIU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST ROCK PAVILION, BASEMENT-ROOM AO-F300
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

12 VALLEY LN
MULLICA HILL NJ
08062-1611
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-9403
  • Fax:
Mailing address:
  • Phone: 856-478-0684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD432025
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: