Provider Demographics
NPI:1275505190
Name:LIAO, KATHERINE GO (MD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:GO
Last Name:LIAO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 ROOSEVELT RD
Mailing Address - Street 2:PO BOX 6
Mailing Address - City:NIAGARA
Mailing Address - State:WI
Mailing Address - Zip Code:54151-1043
Mailing Address - Country:US
Mailing Address - Phone:888-724-6377
Mailing Address - Fax:715-251-1681
Practice Address - Street 1:1601 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:NIAGARA
Practice Address - State:WI
Practice Address - Zip Code:54151-1043
Practice Address - Country:US
Practice Address - Phone:715-251-1780
Practice Address - Fax:715-251-1787
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42715-020207LP2900X, 208VP0014X
MI4301077176207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI050B210120OtherBCBS
1027531OtherPREFERRED ONE
MI4782601Medicaid
MI4782568Medicaid
WI34051000Medicaid
MI4782512Medicaid
WI050077649OtherRAILROAD MEDICARE
MI4259562Medicaid
MI050077646OtherRAILROAD MEDICARE
MI050B210120OtherBCBS
MI050077646OtherRAILROAD MEDICARE
WI050077649OtherRAILROAD MEDICARE
WI40015-0008Medicare ID - Type Unspecified
MI4782601Medicaid
WI600560002Medicare PIN