1568467561 NPI number — DR. ANDREW G LIBERTIN M.D.

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568467561 NPI number — DR. ANDREW G LIBERTIN M.D.

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

LIBERTIN

Provider First Name:

ANDREW

Provider Middle Name:

G

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

M.D.

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1568467561

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

03/18/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

7777 HEARTHSTONE AVE NW

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

CANTON

Provider Business Mailing Address State Name:

OH

Provider Business Mailing Address Postal Code:

44720-6971

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

234-237-9932

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

832 S MAIN ST

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

ORRVILLE

Provider Business Practice Location Address State Name:

OH

Provider Business Practice Location Address Postal Code:

44667-2208

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

330-684-4771

Provider Business Practice Location Address Fax Number:

330-684-2075

Provider Enumeration Date:

06/16/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RG0100X , with the licence number:  35.055141 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 4307999 . This is a "AETNA #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 100013700 . This is a "RR MEDICARE PIN #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: CC9333 . This is a "RR MEDICARE GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 0975888 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 341773267D . This is a "AULTCARE #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 91656 . This is a "QUALCHOICE #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 2900613 . This is a "UNITED HEALTHCARE #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 341773267 . This is a "COMMERCIA CARRIERS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 0696064 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
• Identifier: 000000138316 . This is a "ANTHEM BCBS #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 2735441001 . This is a "CIGNA #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
• Identifier: 34177326700 . This is a "BWC GROUP #" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".