Basic Information
| Provider Information | |||||||||
| NPI: | 1669418745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEBREICH | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 41 UNIVERSITY DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NEWTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 189401873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159461500 | ||||||||
| FaxNumber: | 2159463417 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 N OXFORD VALLEY RD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | FAIRLESS HILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190302624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159461500 | ||||||||
| FaxNumber: | 2159463417 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD044551E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30165548 | 01 | PA | KEYSTONE FIRST | OTHER | 3266287 | 01 | PA | CIGNA PA | OTHER | 626085 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0014906860006 | 05 | PA | MEDICAID | 0455758000 | 01 | PA | KEYSTONE IBC | OTHER | 4218757 | 01 | PA | AETNA | OTHER | P01193815 | 01 | PA | RAILROAD MEDICARE | OTHER |