Provider Demographics
NPI:1598850653
Name:LIEBROSS, ROBERT HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HOWARD
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 1:6100 W 96TH ST
Mailing Address - Street 2:SUITE 125
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278-6005
Mailing Address - Country:US
Mailing Address - Phone:317-715-1800
Mailing Address - Fax:317-715-6200
Practice Address - Street 1:8402 HARCOURT ROAD
Practice Address - Street 2:SUITE 721
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-415-6760
Practice Address - Fax:317-415-6758
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010523672085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01052367BOtherCSR
IN200269520Medicaid
IN200259350Medicaid
IN200259350Medicaid
IN200259350Medicaid
INP00480012Medicare PIN
IN246800Medicare PIN
IN149720EEMedicare PIN
IN01052367BOtherCSR
H15861Medicare UPIN