Provider Demographics
NPI:1770706764
Name:LIBERTY MEDICAL CENTER INC
Entity type:Organization
Organization Name:LIBERTY MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RABIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-942-8080
Mailing Address - Street 1:425 E US ROUTE 6
Mailing Address - Street 2:SUITE A
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-9042
Mailing Address - Country:US
Mailing Address - Phone:815-942-8080
Mailing Address - Fax:815-513-5267
Practice Address - Street 1:425 E US ROUTE 6
Practice Address - Street 2:SUITE A
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-9042
Practice Address - Country:US
Practice Address - Phone:815-942-8080
Practice Address - Fax:815-513-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-087831207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-087831Medicaid
ILK17020Medicare PIN
ILK17021Medicare PIN
IL036-087831Medicaid
IL209143Medicare PIN