Provider Demographics
NPI:1639771348
Name:LIBERTY ORTHOPEDICS PS
Entity Type:Organization
Organization Name:LIBERTY ORTHOPEDICS PS
Other - Org Name:LIBERTY KNEE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:REID
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:360-801-7966
Mailing Address - Street 1:20696 BOND RD NE STE 205
Mailing Address - Street 2:
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-9025
Mailing Address - Country:US
Mailing Address - Phone:360-930-0222
Mailing Address - Fax:360-210-1429
Practice Address - Street 1:20696 BOND RD NE STE 205
Practice Address - Street 2:
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-9025
Practice Address - Country:US
Practice Address - Phone:360-930-0222
Practice Address - Fax:360-210-1429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-09
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2169137Medicaid