Provider Demographics
NPI:1629254271
Name:MARCIA A. LIBERATORE, MD PC
Entity Type:Organization
Organization Name:MARCIA A. LIBERATORE, MD PC
Other - Org Name:CORVALLIS INTEGRAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:ANTOINETTE
Authorized Official - Last Name:LIBERATORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-753-1172
Mailing Address - Street 1:PMB 191
Mailing Address - Street 2:922 NW CIRCLE BLVD, STE 160
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-1410
Mailing Address - Country:US
Mailing Address - Phone:541-753-1172
Mailing Address - Fax:541-752-9935
Practice Address - Street 1:917 NW GRANT AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4570
Practice Address - Country:US
Practice Address - Phone:541-753-1172
Practice Address - Fax:541-752-9935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24224261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORE50329Medicare UPIN
ORR131896Medicare PIN