Provider Demographics
NPI:1902882210
Name:LIBERTY LABORATORY INC
Entity Type:Organization
Organization Name:LIBERTY LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATE
Authorized Official - Prefix:
Authorized Official - First Name:VERONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-548-0086
Mailing Address - Street 1:4531 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-1614
Mailing Address - Country:US
Mailing Address - Phone:812-619-0413
Mailing Address - Fax:708-318-4182
Practice Address - Street 1:1317 119TH ST
Practice Address - Street 2:
Practice Address - City:WHITING
Practice Address - State:IN
Practice Address - Zip Code:46394-1602
Practice Address - Country:US
Practice Address - Phone:219-629-4030
Practice Address - Fax:708-488-1831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D1019268291U00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000311554OtherBCBS NUMBER
IN300024950Medicaid