Provider Demographics
NPI:1659822864
Name:LIBERTAS CORP.
Entity Type:Organization
Organization Name:LIBERTAS CORP.
Other - Org Name:FREESTATE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:YAGHMAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-924-8140
Mailing Address - Street 1:4723 E DOUGLAS AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67218-1012
Mailing Address - Country:US
Mailing Address - Phone:800-924-8140
Mailing Address - Fax:800-924-8140
Practice Address - Street 1:4723 E DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1012
Practice Address - Country:US
Practice Address - Phone:800-924-8140
Practice Address - Fax:800-924-8140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-33447207P00000X, 207R00000X, 208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty