Provider Demographics
NPI:1528623329
Name:LIBERTY MEDICAL DEVELOPMENT, LLC
Entity type:Organization
Organization Name:LIBERTY MEDICAL DEVELOPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:340-779-2663
Mailing Address - Street 1:PO BOX 11567
Mailing Address - Street 2:
Mailing Address - City:ST THOMAS
Mailing Address - State:VI
Mailing Address - Zip Code:00801-4567
Mailing Address - Country:US
Mailing Address - Phone:340-779-2663
Mailing Address - Fax:340-779-2443
Practice Address - Street 1:4006 ESTATE DIAMOND STE 203
Practice Address - Street 2:
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820-4534
Practice Address - Country:US
Practice Address - Phone:340-718-2664
Practice Address - Fax:340-779-2443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-07
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory SurgicalGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac FacilitiesGroup - Multi-Specialty