Basic Information
| Provider Information | |||||||||
| NPI: | 1528623329 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY MEDICAL DEVELOPMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11567 | ||||||||
| Address2: | |||||||||
| City: | ST THOMAS | ||||||||
| State: | VI | ||||||||
| PostalCode: | 008014567 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3407792663 | ||||||||
| FaxNumber: | 3407792443 | ||||||||
| Practice Location | |||||||||
| Address1: | 4006 ESTATE DIAMOND STE 203 | ||||||||
| Address2: | |||||||||
| City: | CHRISTIANSTED | ||||||||
| State: | VI | ||||||||
| PostalCode: | 008204534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3407182664 | ||||||||
| FaxNumber: | 3407792443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2019 | ||||||||
| LastUpdateDate: | 05/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | BACOT | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3407792663 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.