MEDICARE: LIBERTY RC INC

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center

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

General Provider Information

NPI Number	:	1477582690
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY RC INC

Provider Business Mailing Address
First Line	:	5200 VIRGINIA WAY
Second Line	:	L & C DEPT
City	:	BRENTWOOD
State	:	TN
Zip	:	37027-7569
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	667 STONELEIGH AVE
Second Line	:	STE 123
City	:	CARMEL
State	:	NY
Zip	:	10512-2455
Country	:	US
Telephone Number	:	845-278-4150
Fax Number	:	845-279-6902

Authorized Official
Title or Position	:	VP, LICENSURE & CERTIFICATION
Name	:	SAMUEL WEY
Credential	:
Telephone Number	:	615-341-6641

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	04/21/2025

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