Provider Demographics
NPI:1821485483
Name:LIBERTY RESOURCES, INC.
Entity Type:Organization
Organization Name:LIBERTY RESOURCES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:M
Authorized Official - Last Name:COYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-425-1004
Mailing Address - Street 1:1045 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13203-2758
Mailing Address - Country:US
Mailing Address - Phone:315-425-1004
Mailing Address - Fax:315-422-4855
Practice Address - Street 1:1045 JAMES ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-2758
Practice Address - Country:US
Practice Address - Phone:315-425-1004
Practice Address - Fax:315-422-4855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3301227R261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04286357Medicaid
NYJ100000206Medicare PIN