Provider Demographics
NPI:1538114046
Name:LIBERTY CIRCLE EAR NOSE & THROAT INC.
Entity Type:Organization
Organization Name:LIBERTY CIRCLE EAR NOSE & THROAT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:ARTURO
Authorized Official - Last Name:ROA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:740-886-9370
Mailing Address - Street 1:96 TOWNSHIP ROAD 369
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PROCTORVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45669
Mailing Address - Country:US
Mailing Address - Phone:740-886-9370
Mailing Address - Fax:740-886-9374
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:740-886-9370
Practice Address - Fax:740-886-9374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17624207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0954356Medicaid
WV3810004605Medicaid
OH0954356Medicaid