Provider Demographics
NPI:1851753321
Name:LIBERTY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LIBERTY MEDICAL GROUP, INC.
Other - Org Name:LIBERTY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SATISH
Authorized Official - Middle Name:
Authorized Official - Last Name:LAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-944-1806
Mailing Address - Street 1:14071 PEYTON DRIVE, #301
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709
Mailing Address - Country:US
Mailing Address - Phone:909-944-1806
Mailing Address - Fax:909-466-6593
Practice Address - Street 1:9227 HAVEN AVENUE, SUITE 375
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-944-1806
Practice Address - Fax:909-466-6593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG76640208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty