Provider Demographics
NPI:1083630370
Name:LIEBSON, PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:LIEBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST
Mailing Address - Street 2:SUITE 1159
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3841
Mailing Address - Country:US
Mailing Address - Phone:312-942-5020
Mailing Address - Fax:312-942-4039
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 1159
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-5020
Practice Address - Fax:312-942-4039
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2009-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-045706207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC39721Medicare UPIN
ILP12274Medicare ID - Type Unspecified