Provider Demographics
NPI:1487948964
Name:LIBERTY MEDICAL CENTER COAL CITY SC
Entity type:Organization
Organization Name:LIBERTY MEDICAL CENTER COAL CITY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HASSNAIN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SYED
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:815-634-4099
Mailing Address - Street 1:4 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:COAL CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60416-1087
Mailing Address - Country:US
Mailing Address - Phone:815-634-4099
Mailing Address - Fax:815-634-4077
Practice Address - Street 1:4 E NORTH ST
Practice Address - Street 2:
Practice Address - City:COAL CITY
Practice Address - State:IL
Practice Address - Zip Code:60416-1087
Practice Address - Country:US
Practice Address - Phone:815-634-4099
Practice Address - Fax:815-634-4077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-02
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-118250207Q00000X
IL03-6127143207Q00000X
IL036-087831207R00000X
IL036-125457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-118250Medicaid
ILT01609OtherMEDICARE PTAN
IL036-087831Medicaid
IL036-125457Medicaid