Provider Demographics
NPI:1720078421
Name:LIEBERT, BRENT BINKLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:BINKLEY
Last Name:LIEBERT
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 1:5731 GREENDALE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-1593
Mailing Address - Country:US
Mailing Address - Phone:515-270-1000
Mailing Address - Fax:515-331-6581
Practice Address - Street 1:5731 GREENDALE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:JOHNSTON
Practice Address - State:IA
Practice Address - Zip Code:50131-1593
Practice Address - Country:US
Practice Address - Phone:515-270-1000
Practice Address - Fax:515-331-6581
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25797207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1720078421OtherBLUE SHIELD
IA1720078421Medicaid
IAA03295Medicare UPIN
IAI21483Medicare PIN
IAIB1436018Medicare PIN