Basic Information
| Provider Information | |||||||||
| NPI: | 1285302430 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIBERTY CLINIC LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1103 E GRACE ST | ||||||||
| Address2: | |||||||||
| City: | RENSSELAER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479783210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198664135 | ||||||||
| FaxNumber: | 2198660803 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 E GRACE ST | ||||||||
| Address2: | |||||||||
| City: | RENSSELAER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479783210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198664135 | ||||||||
| FaxNumber: | 2198660803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2021 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEHMAN | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
| AuthorizedOfficialMiddleName: | CURTIS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2198664135 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 1912388414 | 01 | INDIVIDUAL NPI | OTHER | 300057753 | 05 | IN | MEDICAID |