MEDICARE: LIBERTY MEDICAL, 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	332B00000X	Durable Medical Equipment & Medical Supplies		MA

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	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609864990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY MEDICAL, LLC

Provider Business Mailing Address
First Line	:	8881 S US HIGHWAY 1
Second Line	:	ATTN: LICENSING DEPARTMENT
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34952-3401
Country	:	US
Telephone Number	:	772-398-2122
Fax Number	:	844-363-4341

Provider Business Practice Location Address
First Line	:	89 MAIN STREET
Second Line	:	SUITE 204
City	:	MILFORD
State	:	MA
Zip	:	01757-3141
Country	:	US
Telephone Number	:	866-202-2420
Fax Number	:	844-363-4341

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JONATHAN BLACK
Credential	:
Telephone Number	:	772-398-2122

Provider Enumeration Date	:	10/11/2005
Last Update Date	:	03/23/2018

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Directions to “LIBERTY MEDICAL, LLC ” Practice Location

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