Provider Demographics
NPI:1205984531
Name:LALIBERTE, BRIAN P (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:LALIBERTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 HUNTERS RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-9046
Mailing Address - Country:US
Mailing Address - Phone:920-682-4319
Mailing Address - Fax:
Practice Address - Street 1:2219 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-2416
Practice Address - Country:US
Practice Address - Phone:920-793-2281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38974207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32381500Medicaid
G53650Medicare UPIN