Provider Demographics
NPI:1841719531
Name:LIBERTY CARDIOLVASCULAR GROUP PLLC
Entity type:Organization
Organization Name:LIBERTY CARDIOLVASCULAR GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PRUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-724-9000
Mailing Address - Street 1:5250 AUTO CLUB DR STE 300L
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2619
Mailing Address - Country:US
Mailing Address - Phone:313-593-8988
Mailing Address - Fax:313-982-1541
Practice Address - Street 1:5250 AUTO CLUB DR STE 300L
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2619
Practice Address - Country:US
Practice Address - Phone:313-593-8988
Practice Address - Fax:313-982-1541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301056091208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4715912Medicaid