MEDICARE: LIBERTY LABORATORY 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	291U00000X	Clinical Medical Laboratory
2	291U00000X	Clinical Medical Laboratory	15D1019268	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000311554	OTHER	IN	BCBS NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902882210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIBERTY LABORATORY INC

Provider Business Mailing Address
First Line	:	4531 HARRISON ST
Second Line	:
City	:	HILLSIDE
State	:	IL
Zip	:	60162-1614
Country	:	US
Telephone Number	:	812-619-0413
Fax Number	:	708-318-4182

Provider Business Practice Location Address
First Line	:	1317 119TH ST
Second Line	:
City	:	WHITING
State	:	IN
Zip	:	46394-1602
Country	:	US
Telephone Number	:	219-629-4030
Fax Number	:	708-488-1831

Authorized Official
Title or Position	:	DELEGATE
Name	:	VERONICA PEREZ
Credential	:
Telephone Number	:	812-548-0086

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	05/08/2024

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