Provider Demographics
NPI:1356525588
Name:LIEBENROOD, JOSEPH (CRNA)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:LIEBENROOD
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 ALBANY RD STE C
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62903-7647
Mailing Address - Country:US
Mailing Address - Phone:618-457-5111
Mailing Address - Fax:
Practice Address - Street 1:35 ALBANY RD STE C
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62903-7647
Practice Address - Country:US
Practice Address - Phone:618-457-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2010-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209007056367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2006023280OtherRN LICENSE