Provider Demographics
NPI:1124117411
Name:LIBERTY DIAGNOSTIC CLINIC
Entity type:Organization
Organization Name:LIBERTY DIAGNOSTIC CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAMID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-427-2149
Mailing Address - Street 1:PO BOX 1905
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77522-1905
Mailing Address - Country:US
Mailing Address - Phone:281-427-2149
Mailing Address - Fax:281-427-4390
Practice Address - Street 1:2802 GARTH RD STE 203
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-3924
Practice Address - Country:US
Practice Address - Phone:281-427-2149
Practice Address - Fax:281-427-4390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085825001Medicaid
TX136448107Medicaid
TX085825001Medicaid