Provider Demographics
NPI:1679835821
Name:LIBERTY CITY COMMUNITY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:LIBERTY CITY COMMUNITY HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-219-8055
Mailing Address - Street 1:9780 E INDIGO ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-5610
Mailing Address - Country:US
Mailing Address - Phone:305-252-9485
Mailing Address - Fax:305-252-9486
Practice Address - Street 1:6112 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33127-1112
Practice Address - Country:US
Practice Address - Phone:305-503-5154
Practice Address - Fax:305-503-5155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78284207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH38819Medicare UPIN