Provider Demographics
NPI:1487630166
Name:LIU, SHAN-LIANG (MD)
Entity Type:Individual
Prefix:
First Name:SHAN-LIANG
Middle Name:
Last Name:LIU
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 1:600 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:MO
Mailing Address - Zip Code:65712-1004
Mailing Address - Country:US
Mailing Address - Phone:417-461-5312
Mailing Address - Fax:417-461-5765
Practice Address - Street 1:600 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:MO
Practice Address - Zip Code:65712-1004
Practice Address - Country:US
Practice Address - Phone:417-461-5312
Practice Address - Fax:417-461-5765
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004016721208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207253303Medicaid
926592629Medicare ID - Type Unspecified
H43945Medicare UPIN