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	HOS3069	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	007CH	OTHER	NC	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1124104757
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	:	1317 N BRIGHTLEAF BLVD STE C
Second Line	:
City	:	SMITHFIELD
State	:	NC
Zip	:	27577-7267
Country	:	US
Telephone Number	:	919-989-6792
Fax Number	:	919-989-8519

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

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	05/05/2010

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Directions to “LIBERTY HEALTHCARE GROUP LLC ” Practice Location

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