Provider Demographics
NPI:1932384518
Name:MARK LIBERTIN, MD, INC.
Entity type:Organization
Organization Name:MARK LIBERTIN, MD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBERTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-605-5900
Mailing Address - Street 1:29001 CEDAR RD STE 201
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-4041
Mailing Address - Country:US
Mailing Address - Phone:440-605-5900
Mailing Address - Fax:
Practice Address - Street 1:29001 CEDAR RD STE 201
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-4041
Practice Address - Country:US
Practice Address - Phone:440-605-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055788L207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9299261Medicare PIN
OHE49965Medicare UPIN