Provider Demographics
NPI:1972833739
Name:LIEBNA MEDICAL CONSULTATIONS PLLC
Entity Type:Organization
Organization Name:LIEBNA MEDICAL CONSULTATIONS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:DR
Authorized Official - First Name:ZELEKE
Authorized Official - Middle Name:DESSE
Authorized Official - Last Name:KASSAHUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-717-4995
Mailing Address - Street 1:5021 SEMINARY RD
Mailing Address - Street 2:APT 1330
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1945
Mailing Address - Country:US
Mailing Address - Phone:301-717-4995
Mailing Address - Fax:
Practice Address - Street 1:1328 SOUTHERN AVE SE
Practice Address - Street 2:STE 205
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4689
Practice Address - Country:US
Practice Address - Phone:202-544-7744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-29
Last Update Date:2009-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD33521207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD699865800Medicaid