Basic Information
| Provider Information | |||||||||
| NPI: | 1245226356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIEB | ||||||||
| FirstName: | DAVID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5501 W 79TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BURBANK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604591784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7738844523 | ||||||||
| FaxNumber: | 7738844580 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 N WABASH AVE | ||||||||
| Address2: | SUITE 2120 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606021903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737269515 | ||||||||
| FaxNumber: | 3127261681 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 10/21/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 036050096 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 036050096 | 05 | IL | MEDICAID | 791062505 | 01 | IL | RAILROAD MEDICARE | OTHER | 21607511 | 01 | IL | BLUE SHIELD | OTHER |