Provider Demographics
NPI:1316055122
Name:LIU, PHILIP G (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:G
Last Name:LIU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431
Mailing Address - Country:US
Mailing Address - Phone:570-253-0202
Mailing Address - Fax:570-253-1701
Practice Address - Street 1:650 PARK STREET
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431
Practice Address - Country:US
Practice Address - Phone:570-253-0202
Practice Address - Fax:570-253-1701
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD -035676E207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1506161OtherLICENSE
PA0010512100001Medicaid
NY1506161OtherLICENSE
PA0010512100001Medicaid