Provider Demographics
NPI:1417902867
Name:LIEBERG, OLAF U (MD)
Entity Type:Individual
Prefix:DR
First Name:OLAF
Middle Name:U
Last Name:LIEBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-8077
Mailing Address - Country:US
Mailing Address - Phone:315-719-0060
Mailing Address - Fax:315-719-0230
Practice Address - Street 1:789 PRE EMPTION RD
Practice Address - Street 2:SUITE 600
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-2069
Practice Address - Country:US
Practice Address - Phone:315-719-0060
Practice Address - Fax:315-719-0230
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY118724207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0598530OtherGHI
100675CUOtherPREFERRED CARE
NY00436508Medicaid
P030118724OtherROCHESTER BLUE SHIELD
P00307208OtherRAILROAD MEDICARE
P010118724OtherBLUE CHOICE
NY1187244WOtherWORKERS COMPENSATION
P010118724OtherBLUE CHOICE