Basic Information
| Provider Information | |||||||||
| NPI: | 1023019544 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEBIG | ||||||||
| FirstName: | THADDEUS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT,ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 W DARLENE ST | ||||||||
| Address2: | PO BOX 107 | ||||||||
| City: | HARTINGTON | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687394510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022543985 | ||||||||
| FaxNumber: | 4022543963 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 W DARLENE ST | ||||||||
| Address2: | |||||||||
| City: | HARTINGTON | ||||||||
| State: | NE | ||||||||
| PostalCode: | 687394510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4022543985 | ||||||||
| FaxNumber: | 4022543963 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 07/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 1065 | SD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 208100000X | 1668 | NE | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 5834080 | 05 | SD | MEDICAID |