Provider Demographics
NPI:1326038159
Name:LIEBERMAN, SCOTT M (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:LIEBERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1783 TROUP HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5869
Mailing Address - Country:US
Mailing Address - Phone:903-595-2283
Mailing Address - Fax:903-595-1063
Practice Address - Street 1:1783 TROUP HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-5869
Practice Address - Country:US
Practice Address - Phone:903-595-2283
Practice Address - Fax:903-595-1063
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6158207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1776475Medicaid
TX045166801OtherSMITH COUNTY INDIGENT
TX060024159OtherPALMETTO GBA
TX060024159OtherRAIL ROAD MEDICARE
TX86K923OtherBCBS OF TEXAS
TX045166801Medicaid
LA1776475Medicaid
TX045166801Medicaid