Provider Demographics
NPI:1174904304
Name:LIU, SEBAN (DO)
Entity type:Individual
Prefix:
First Name:SEBAN
Middle Name:
Last Name:LIU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N WALL ST
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-2942
Mailing Address - Country:US
Mailing Address - Phone:844-404-4787
Mailing Address - Fax:815-936-3243
Practice Address - Street 1:500 N WALL ST
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-2942
Practice Address - Country:US
Practice Address - Phone:844-404-4787
Practice Address - Fax:815-936-3242
Is Sole Proprietor?:No
Enumeration Date:2015-06-12
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036157303207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program