Provider Demographics
NPI:1659775500
Name:LIBERTY FAMILY PHYSICIANS
Entity Type:Organization
Organization Name:LIBERTY FAMILY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:EMERY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:704-844-0505
Mailing Address - Street 1:1928 WEDDINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WEDDINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28104-8318
Mailing Address - Country:US
Mailing Address - Phone:704-844-0505
Mailing Address - Fax:704-844-0220
Practice Address - Street 1:1928 WEDDINGTON RD
Practice Address - Street 2:
Practice Address - City:WEDDINGTON
Practice Address - State:NC
Practice Address - Zip Code:28104-8318
Practice Address - Country:US
Practice Address - Phone:704-844-0505
Practice Address - Fax:704-844-0220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-20
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC205382207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ0059WMedicaid
NC89134FAMedicaid
NCNC1769BMedicare PIN
2022387Medicare PIN
SCQ0059WMedicaid
NC2022387AMedicare PIN
NC89134FAMedicaid