Provider Demographics
NPI:1457311094
Name:LIBERTY PEDIATRICS, LLC
Entity Type:Organization
Organization Name:LIBERTY PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:HICKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-549-0900
Mailing Address - Street 1:1030 LIBERTY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7941
Mailing Address - Country:US
Mailing Address - Phone:410-549-0900
Mailing Address - Fax:410-549-6121
Practice Address - Street 1:1030 LIBERTY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-7941
Practice Address - Country:US
Practice Address - Phone:410-549-0900
Practice Address - Fax:410-549-6121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-27
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD2977028Medicaid
MD2977028Medicaid