Provider Demographics
NPI:1518023498
Name:LIEBROSS, BERTRAM SIDNEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BERTRAM
Middle Name:SIDNEY
Last Name:LIEBROSS
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 1:55 GREENLEAF HL
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-1809
Mailing Address - Country:US
Mailing Address - Phone:516-829-3794
Mailing Address - Fax:516-829-3794
Practice Address - Street 1:55 GREENLEAF HL
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023-1809
Practice Address - Country:US
Practice Address - Phone:516-829-3794
Practice Address - Fax:516-829-3794
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101408207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY55007Medicare ID - Type UnspecifiedGHI MEDICARE
NYB16753Medicare UPIN