Provider Demographics
NPI:1285302430
Name:LIBERTY CLINIC LLC
Entity type:Organization
Organization Name:LIBERTY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:CURTIS
Authorized Official - Last Name:LEHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:219-866-4135
Mailing Address - Street 1:1103 E GRACE ST
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-3210
Mailing Address - Country:US
Mailing Address - Phone:219-866-4135
Mailing Address - Fax:219-866-0803
Practice Address - Street 1:1103 E GRACE ST
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-3210
Practice Address - Country:US
Practice Address - Phone:219-866-4135
Practice Address - Fax:219-866-0803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1912388414OtherINDIVIDUAL NPI
IN300057753Medicaid