Basic Information
| Provider Information | |||||||||
| NPI: | 1598850653 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIEBROSS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | HOWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6100 W 96TH ST | ||||||||
| Address2: | SUITE 125 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462786005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177151800 | ||||||||
| FaxNumber: | 3177156200 | ||||||||
| Practice Location | |||||||||
| Address1: | 8402 HARCOURT ROAD | ||||||||
| Address2: | SUITE 721 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3174156760 | ||||||||
| FaxNumber: | 3174156758 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 01052367 | IN | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | BL5937024 | 01 | IN | DEA | OTHER | 01052367B | 01 | IN | CSR | OTHER | 200269520 | 05 | IN | MEDICAID | 200259350 | 05 | IN | MEDICAID |