Provider Demographics
NPI:1538123724
Name:HOBERMAN, LIBERTY BELLE SHELTON (MD)
Entity Type:Individual
Prefix:DR
First Name:LIBERTY BELLE
Middle Name:SHELTON
Last Name:HOBERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 136TH AVE
Mailing Address - Street 2:SUITE 416
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2923
Mailing Address - Country:US
Mailing Address - Phone:616-738-0470
Mailing Address - Fax:616-738-0498
Practice Address - Street 1:400 136TH AVE
Practice Address - Street 2:SUITE 416
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2923
Practice Address - Country:US
Practice Address - Phone:616-738-0470
Practice Address - Fax:616-738-0498
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301068128208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI020G010060OtherBLUE CROSS BLUE SHIELD MI
MI4783476Medicaid
382809956OtherCOMMERCIAL
MIH47612Medicare UPIN
MIOM12440Medicare ID - Type Unspecified