Provider Demographics
NPI:1942373675
Name:LIBERTY MEDICAL PRACTICE P.C
Entity Type:Organization
Organization Name:LIBERTY MEDICAL PRACTICE P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SALAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:718-859-8808
Mailing Address - Street 1:2848 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-4106
Mailing Address - Country:US
Mailing Address - Phone:718-941-2200
Mailing Address - Fax:718-703-0872
Practice Address - Street 1:2848 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-4106
Practice Address - Country:US
Practice Address - Phone:718-941-2200
Practice Address - Fax:718-703-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Not Answered261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEW871Medicare ID - Type Unspecified