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	HOS3058	NC

Other Identifiers

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

General Provider Information

NPI Number	:	1013093921
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	:	3200 SPRING FOREST RD STE 201
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-2812
Country	:	US
Telephone Number	:	919-850-4303
Fax Number	:	919-850-4304

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. ANTHONY J ZIZZAMIA JR.
Credential	:
Telephone Number	:	910-815-3122

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	04/20/2009

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