Provider Demographics
NPI:1639166853
Name:LIEBL, R SCOTT (MD)
Entity type:Individual
Prefix:
First Name:R
Middle Name:SCOTT
Last Name:LIEBL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:835 S MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OCONTO FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54154-1241
Mailing Address - Country:US
Mailing Address - Phone:920-846-8424
Mailing Address - Fax:920-846-2073
Practice Address - Street 1:835 S MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OCONTO FALLS
Practice Address - State:WI
Practice Address - Zip Code:54154-1241
Practice Address - Country:US
Practice Address - Phone:920-846-8424
Practice Address - Fax:920-846-2073
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI21763020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11014110Medicaid
1851477913OtherNPI
WI390848401050OtherBXBS
WI30189000Medicaid
WI52Z310Medicare Oscar/Certification
WI521310Medicare Oscar/Certification
WI30189000Medicaid
WI00439Medicare PIN
WI390848401050OtherBXBS