Provider Demographics
NPI:1770641581
Name:LIEB, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LIEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GRANT AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-4378
Mailing Address - Country:US
Mailing Address - Phone:215-464-7222
Mailing Address - Fax:215-464-6025
Practice Address - Street 1:2000 GRANT AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19115-4378
Practice Address - Country:US
Practice Address - Phone:215-464-7222
Practice Address - Fax:215-464-6025
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040345L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1071689Medicaid
PAC34638Medicare UPIN
PA484538Medicare ID - Type Unspecified