Provider Demographics
NPI:1770575623
Name:LIBERTY DIAGNOSTIC PATHOLOGY PA
Entity type:Organization
Organization Name:LIBERTY DIAGNOSTIC PATHOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:DR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STRAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-915-2485
Mailing Address - Street 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-434-9309
Mailing Address - Fax:315-454-0136
Practice Address - Street 1:355 GRAND ST
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302-4321
Practice Address - Country:US
Practice Address - Phone:201-915-2485
Practice Address - Fax:201-915-2377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9027009Medicaid
NJ9027009Medicaid