Provider Demographics
NPI:1407942196
Name:LIEBENSPERGER-CAVALL, IRENE
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:
Last Name:LIEBENSPERGER-CAVALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:NC
Mailing Address - Zip Code:27925-0189
Mailing Address - Country:US
Mailing Address - Phone:252-796-0689
Mailing Address - Fax:252-796-0690
Practice Address - Street 1:208 NORTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:NC
Practice Address - Zip Code:27925-9705
Practice Address - Country:US
Practice Address - Phone:252-796-0689
Practice Address - Fax:252-796-0690
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC61176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ28272Medicare UPIN
NC343923Medicare ID - Type Unspecified