Provider Demographics
NPI:1013126614
Name:JEFFREY M LIEBLICH MD SC
Entity Type:Organization
Organization Name:JEFFREY M LIEBLICH MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIEBLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD,SC
Authorized Official - Phone:847-432-5510
Mailing Address - Street 1:1971 2ND ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60035-3174
Mailing Address - Country:US
Mailing Address - Phone:847-432-5510
Mailing Address - Fax:847-432-5526
Practice Address - Street 1:1971 2ND ST
Practice Address - Street 2:SUITE 100
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-3174
Practice Address - Country:US
Practice Address - Phone:847-432-5510
Practice Address - Fax:847-432-5526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047697174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036047697Medicaid
IL036047697Medicaid
ILD93803Medicare UPIN