MEDICARE: LIBERTY HEALTHCARE GROUP, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency	HOS3048	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007A	OTHER	NC	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003995937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY HEALTHCARE GROUP, LLC

Provider Business Mailing Address
First Line	:	2334 S 41ST ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28403-5502
Country	:	US
Telephone Number	:	910-815-3122
Fax Number	:	910-815-3111

Provider Business Practice Location Address
First Line	:	1206 ARENDELL STREET, MOREHEAD CITY, NC 28557-4145
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-4145
Country	:	US
Telephone Number	:	252-247-4848
Fax Number	:	252-247-2445

Authorized Official
Title or Position	:	PRESIDENT/EXECUTIVE
Name	:	MR. ANTHONY J. ZIZZAMAI JR.
Credential	:	RN
Telephone Number	:	910-815-3122

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	05/05/2010

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