Provider Demographics
NPI:1356429864
Name:KAREN D LIBSCH MD PC
Entity type:Organization
Organization Name:KAREN D LIBSCH MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-564-9777
Mailing Address - Street 1:PO BOX 1297
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-1297
Mailing Address - Country:US
Mailing Address - Phone:970-564-9777
Mailing Address - Fax:970-564-8833
Practice Address - Street 1:118 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3104
Practice Address - Country:US
Practice Address - Phone:970-564-9777
Practice Address - Fax:970-564-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72571322Medicaid
CO72571322Medicaid
G84243Medicare UPIN