Provider Demographics
NPI:1114657384
Name:LIWAG, KIMBERLY T
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:T
Last Name:LIWAG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 BUSCH PKWY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-2686
Mailing Address - Country:US
Mailing Address - Phone:847-419-7150
Mailing Address - Fax:
Practice Address - Street 1:1501 BUSCH PKWY
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-2686
Practice Address - Country:US
Practice Address - Phone:847-419-7150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2022-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008464208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation