Provider Demographics
NPI:1952442550
Name:LIBERTY FOOT &ANKLE CENTER
Entity Type:Organization
Organization Name:LIBERTY FOOT &ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-255-8805
Mailing Address - Street 1:1749 HOOPER AVE
Mailing Address - Street 2:STE.101
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-8130
Mailing Address - Country:US
Mailing Address - Phone:732-255-8805
Mailing Address - Fax:
Practice Address - Street 1:933 LACEY RD
Practice Address - Street 2:SUITE 3
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1049
Practice Address - Country:US
Practice Address - Phone:732-255-8805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD002445213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5969140001Medicare NSC