Provider Demographics
NPI:1760445399
Name:LIEBERT, RAINER B (PT)
Entity Type:Individual
Prefix:MR
First Name:RAINER
Middle Name:B
Last Name:LIEBERT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1903 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-5200
Mailing Address - Country:US
Mailing Address - Phone:269-387-3248
Mailing Address - Fax:269-387-2744
Practice Address - Street 1:1903 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-5200
Practice Address - Country:US
Practice Address - Phone:269-387-3248
Practice Address - Fax:269-387-2744
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009158225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C912400OtherBLUE CROSS
MIP06360001Medicare ID - Type Unspecified
MI5824480001Medicare NSC