Provider Demographics
NPI:1992036651
Name:LIEBENGOOD, SERENA MCCLAM (MD, MHS)
Entity Type:Individual
Prefix:DR
First Name:SERENA
Middle Name:MCCLAM
Last Name:LIEBENGOOD
Suffix:
Gender:F
Credentials:MD, MHS
Other - Prefix:DR
Other - First Name:SERENA
Other - Middle Name:LYNN
Other - Last Name:MCCLAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, MHS
Mailing Address - Street 1:PO BOX 64358
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4358
Mailing Address - Country:US
Mailing Address - Phone:410-356-8186
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-955-9446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-20
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC95572752085R0202X
MDD703192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD035196200Medicaid
MD186110YSJMedicare PIN