LIBERTY MEDICAL, LLC

Provider Demographics

• NPI: 1609864990
• Name: LIBERTY MEDICAL, LLC
• Entity Type: Organization
• Organization Name: LIBERTY MEDICAL, LLC
• Authorized Official - Title/Position: PRESIDENT
• Authorized Official - First Name: JONATHAN
• Authorized Official - Last Name: BLACK
• Authorized Official - Phone: 772-398-2122
• Mailing Address - Street 1: 8881 S US HIGHWAY 1
• Mailing Address - Street 2: ATTN: LICENSING DEPARTMENT
• Mailing Address - City: PORT ST LUCIE
• Mailing Address - State: FL
• Mailing Address - Zip Code: 34952-3401
• Mailing Address - Country: US
• Mailing Address - Phone: 772-398-2122
• Mailing Address - Fax: 844-363-4341
• Practice Address - Street 1: 89 MAIN STREET
• Practice Address - Street 2: SUITE 204
• Practice Address - City: MILFORD
• Practice Address - State: MA
• Practice Address - Zip Code: 01757-3141
• Practice Address - Country: US
• Practice Address - Phone: 866-202-2420
• Practice Address - Fax: 844-363-4341
• EIN: <UNAVAIL>
• Is Organization Subpart?: Yes
• Parent Organization LBN: LIBERTY MEDICAL HOLDINGS, LLC
• Parent Organization TIN: <UNAVAIL>
• Enumeration Date: 2005-10-11
• Last Update Date: 2018-03-23

Provider Licenses

State	License ID	Taxonomies
MA		332B00000X, 332B00000X
MA	DS89779	3336M0002X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	332B00000X	Suppliers	Durable Medical Equipment & Medical Supplies		Group - Single Specialty
No	3336M0002X	Suppliers	Pharmacy	Mail Order Pharmacy

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NH	30703422	Medicaid
MA	110020874E	Medicaid
TX	1557308-01	Medicaid
PA	1024762540001	Medicaid
NH	30703422	Medicaid
MA	687042	Other	TUFTS HEALTH PLAN
MA	82-00603	Other	EVERCARE
FL	031984800	Medicaid
MA	1228070001	Medicare NSC
MA	391254	Other	BLUE CROSS BLUE SHIELD
KY	7100100090	Medicaid
TN	1519416	Medicaid
TX	1557308-01	Medicaid
NH	12Y004854NH01	Other	ANTHEM BCBS
ME	155140000	Medicaid
VT	1011734	Medicaid
NH	30703422	Medicaid
PA	1024762540001	Medicaid
MD	035218700	Medicaid
PA	1024762540001	Medicaid
MD	035218700	Medicaid
RI	8070001	Medicaid