Provider Demographics
NPI:1881644615
Name:ROGER D. LIEBERMAN, D.O.
Entity Type:Organization
Organization Name:ROGER D. LIEBERMAN, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MADY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-327-2770
Mailing Address - Street 1:PO BOX 1128
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08332-8128
Mailing Address - Country:US
Mailing Address - Phone:856-327-2770
Mailing Address - Fax:856-327-9686
Practice Address - Street 1:1601 N 2ND ST
Practice Address - Street 2:SUITE C4
Practice Address - City:MILLVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08332-1924
Practice Address - Country:US
Practice Address - Phone:856-327-2770
Practice Address - Fax:856-327-9686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04048000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0575003Medicaid
NJ4089909OtherAETNA
NJ0K0643OtherHEALTH NET
NJCBS048OtherOXFORD
NJ0107916000OtherAMERIHEALTH
NJ0575003Medicaid
NJ180004197Medicare PIN
NJ472983Medicare PIN