Provider Demographics
NPI:1700990314
Name:LIAO, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:LIAO
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:PO BOX 102
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-0102
Mailing Address - Country:US
Mailing Address - Phone:989-269-9819
Mailing Address - Fax:989-269-5212
Practice Address - Street 1:1100 S VAN DYKE
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413
Practice Address - Country:US
Practice Address - Phone:989-269-9521
Practice Address - Fax:989-269-7948
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI039148207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1501860Medicaid
MI2213200311OtherBS
MI2213200311OtherBS
MI1501860Medicaid