Provider Demographics
NPI:1346202108
Name:LIEBENBERG, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LIEBENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 EAST OLNEY AVENUE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19120
Mailing Address - Country:US
Mailing Address - Phone:215-456-7000
Mailing Address - Fax:215-254-2599
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:WCB BLDG 4TH FL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141
Practice Address - Country:US
Practice Address - Phone:215-456-7900
Practice Address - Fax:215-456-3428
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020513E207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007225610009Medicaid
B31943Medicare UPIN
0126035PDMedicare ID - Type Unspecified