1629254271 NPI number — MARCIA A. LIBERATORE, MD PC

Table of content: (NPI 1629254271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629254271 NPI number — MARCIA A. LIBERATORE, MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARCIA A. LIBERATORE, MD PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CORVALLIS INTEGRAL MEDICINE
Provider Other Organization Name Type Code:
3
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 Information

NPI Number:
1629254271
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PMB 191
Provider Second Line Business Mailing Address:
922 NW CIRCLE BLVD, STE 160
Provider Business Mailing Address City Name:
CORVALLIS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97330-1410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-753-1172
Provider Business Mailing Address Fax Number:
541-752-9935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
917 NW GRANT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORVALLIS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97330-4570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-753-1172
Provider Business Practice Location Address Fax Number:
541-752-9935
Provider Enumeration Date:
01/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LIBERATORE
Authorized Official First Name:
MARCIA
Authorized Official Middle Name:
ANTOINETTE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-753-1172

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  MD24224 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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