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General NPI Number Information
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NPI Number | 1134563125
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Entity Type | Organization
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Legal Business Name | LIBERTY WELLCARE, PLLC
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Dates
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Enumeration Date | 04/22/2013
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Last Update Date | 04/22/2013
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Provider Practice Location Address
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Address Line | 216 BLUFFWOOD DR
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City | DANVILLE
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State | KY
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Zip | 40422-9788
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Country | US
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Telephone | 859-238-7756
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Fax | 270-378-5786
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Provider Business Mailing Address
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Address Line | 216 BLUFFWOOD DR
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City | DANVILLE
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State | KY
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Zip | 40422-9788
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Country | US
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Telephone | 859-238-7756
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Fax | 270-378-5786
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Authorized Official
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Title or Position | CEO
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Name | DR. IMAD A HADDAD
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Credential | MD
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Telephone | 859-238-7756
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 37821
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License Number State | KY
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