Provider Demographics
NPI:1770553372
Name:LIVERMONT, RONALD EDWIN (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:EDWIN
Last Name:LIVERMONT
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 1:1000 HEALTH CENTER ROAD
Mailing Address - Street 2:
Mailing Address - City:KYLE
Mailing Address - State:SD
Mailing Address - Zip Code:57752-0000
Mailing Address - Country:US
Mailing Address - Phone:605-455-8214
Mailing Address - Fax:605-455-1529
Practice Address - Street 1:1000 HEALTH CENTER ROAD
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:SD
Practice Address - Zip Code:57752-0000
Practice Address - Country:US
Practice Address - Phone:605-455-8214
Practice Address - Fax:605-455-1529
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2013207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD21031Medicaid
E33742Medicare UPIN
AKMD21031Medicaid