Provider Demographics
NPI:1821083908
Name:LIEBRECHT, PAUL CONRAD (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:CONRAD
Last Name:LIEBRECHT
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 1:333 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2246
Mailing Address - Country:US
Mailing Address - Phone:276-236-8155
Mailing Address - Fax:276-236-8899
Practice Address - Street 1:333 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2246
Practice Address - Country:US
Practice Address - Phone:276-236-8155
Practice Address - Fax:276-236-8899
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039317174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI006496628Medicaid
VIB60166Medicare UPIN
VI200001151Medicare ID - Type Unspecified