Basic Information
| Provider Information | |||||||||
| NPI: | 1598275703 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIBERTY ENDOSCOPY CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2925 VERNON PL STE 100 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452192425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137516667 | ||||||||
| FaxNumber: | 5135691344 | ||||||||
| Practice Location | |||||||||
| Address1: | 7360 LIBERTY ONE DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY TOWNSHIP | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135691310 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2017 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | WALKER | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5135691310 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QA1903X | 1207AS | OH | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.