Healthcare Provider Details

I. General information

NPI: 1639166853
Provider Name (Legal Business Name): R SCOTT LIEBL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S MAIN ST SUITE 1
OCONTO FALLS WI
54154-1241
US

IV. Provider business mailing address

835 S MAIN ST SUITE 1
OCONTO FALLS WI
54154-1241
US

V. Phone/Fax

Practice location:
  • Phone: 920-846-8424
  • Fax: 920-846-2073
Mailing address:
  • Phone: 920-846-8424
  • Fax: 920-846-2073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number21763020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: