Provider Demographics
NPI:1225121221
Name:LEIBERT E. DEVINE MD PA
Entity Type:Organization
Organization Name:LEIBERT E. DEVINE MD PA
Other - Org Name:FAMILY MEDICINE OF EDENTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-482-7774
Mailing Address - Street 1:314 W QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-1733
Mailing Address - Country:US
Mailing Address - Phone:252-482-7774
Mailing Address - Fax:252-482-7345
Practice Address - Street 1:314 W QUEEN ST
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1733
Practice Address - Country:US
Practice Address - Phone:252-482-7774
Practice Address - Fax:252-482-7345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8923374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2345604Medicare ID - Type Unspecified