Provider Demographics
NPI:1407877004
Name:LIEBERMAN, JAY ADAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:ADAM
Last Name:LIEBERMAN
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 1:850 POPLAR AVE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-4607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 N DUNLAP ST
Practice Address - Street 2:SUITE 400
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-4625
Practice Address - Country:US
Practice Address - Phone:901-287-7337
Practice Address - Fax:901-266-6488
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006015608207R00000X
TN48645207KA0200X, 207K00000X
NY254120-1207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1528562Medicaid