Basic Information
| Provider Information | |||||||||
| NPI: | 1770575623 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIBERTY DIAGNOSTIC PATHOLOGY PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4567 CROSSROADS PARK DR | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130883589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154349309 | ||||||||
| FaxNumber: | 3154540136 | ||||||||
| Practice Location | |||||||||
| Address1: | 355 GRAND ST | ||||||||
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| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073024321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019152485 | ||||||||
| FaxNumber: | 2019152377 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 09/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | STRAND | ||||||||
| AuthorizedOfficialFirstName: | CALVIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2019152485 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 9027009 | 05 | NJ | MEDICAID |