Basic Information
| Provider Information | |||||||||
| NPI: | 1033733548 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIEBERMAN | ||||||||
| FirstName: | MELISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2424 SEMINOLE CT | ||||||||
| Address2: | |||||||||
| City: | RIVERWOODS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600153853 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1675 DEMPSTER ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | PARK RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600681110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473189330 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2020 | ||||||||
| LastUpdateDate: | 07/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363AS0400X | 085.008424 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.