Basic Information
| Provider Information | |||||||||
| NPI: | 1225067804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIAO | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PHD., MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2201 CHAPEL AVE W | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564886500 | ||||||||
| FaxNumber: | 8564886507 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 CHAPEL AVE W | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080022048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564886500 | ||||||||
| FaxNumber: | 8564886507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 04/27/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 230213 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 25MA08070600 | NJ | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2360963 | 01 | NJ | UNITED HEALTHCARE | OTHER | 2779286000 | 01 | NJ | AMERIHEALTH/KEYSTONE/IBC | OTHER | 02496871 | 05 | NY | MEDICAID | 60026657 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 3818841 | 01 | NJ | CIGNA | OTHER | 1352535 | 01 | NJ | AETNA | OTHER | P3737619 | 01 | NJ | OXFORD | OTHER | 01077798200 | 01 | NJ | AMERICHOICE | OTHER | 0119636 | 05 | NJ | MEDICAID |