=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659125185
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY MEDICAL ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2024
-----------------------------------------------------
Last Update Date | 04/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 506 CENTRAL AVE
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07050-1432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-218-8422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 146 BREWSTER AVE
-----------------------------------------------------
City | PISCATAWAY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08854-2229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-218-8422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. TARIQ MAHMOOD
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 201-218-8422
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------