Provider Demographics
NPI:1871537563
Name:LIEB, THOMAS F (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:F
Last Name:LIEB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 NE 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4144
Mailing Address - Country:US
Mailing Address - Phone:314-402-6504
Mailing Address - Fax:
Practice Address - Street 1:2020 NE 61ST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213
Practice Address - Country:US
Practice Address - Phone:314-402-6504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR4N13208100000X
WAMD00021605208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4668145OtherAETNA
MO2300462OtherUNITED HEALTHCARE
MO188614OtherBLUE CROSS BLUE SHIELD
MO21373V3223OtherGROUP HEATH PLAN
MO6741899001OtherCIGNA
MOP00146328OtherRAILROAD MEDICARE
MO136709OtherHEALTHLINK
MO202879714Medicaid
MO21373V3223OtherGROUP HEATH PLAN
MO909542295Medicare PIN