1336111038 NPI number — ROBERTA E GEBHARD DO

Table of content: ROBERTA E GEBHARD DO (NPI 1336111038)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336111038 NPI number — ROBERTA E GEBHARD DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GEBHARD
Provider First Name:
ROBERTA
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336111038
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 CARDINAL LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14072-1950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-649-0887
Provider Business Mailing Address Fax Number:
716-646-4611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
621 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NIAGARA FALLS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14301-1813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-692-3302
Provider Business Practice Location Address Fax Number:
716-692-4342
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  176365 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01607583 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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