Provider Demographics
NPI:1164427910
Name:LIEDMAN, CARL NELSON (DO)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:NELSON
Last Name:LIEDMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 E HUNTING PARK AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-4800
Mailing Address - Country:US
Mailing Address - Phone:215-535-4494
Mailing Address - Fax:215-535-4203
Practice Address - Street 1:841 E HUNTING PARK AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-4800
Practice Address - Country:US
Practice Address - Phone:215-535-4494
Practice Address - Fax:215-535-4203
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA193400000X207Q00000X
PAOS004520L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0075139402OtherAMERICHOICE
PA6128979OtherCIGNA
PA100008OtherKEYSTONE MERCY
PA110159242OtherTRAVELORS
PA173358OtherBLUE SHIELD
PA108074OtherAETNA
PAPA10333OtherELDER HEALTH
PA00422OtherHEALTH PARTNERS
NJ3548201Medicare ID - Type Unspecified
PA108074OtherAETNA
PA127902Medicare ID - Type Unspecified