1679512396 NPI number — JANET MARY TIBERIA PNP

Table of content: JANET MARY TIBERIA PNP (NPI 1679512396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679512396 NPI number — JANET MARY TIBERIA PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIBERIA
Provider First Name:
JANET
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CARMODY
Provider Other First Name:
JANET
Provider Other Middle Name:
MARY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679512396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 BAYBERRY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POESTENKILL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12140-2309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1092 MADISON AVE
Provider Second Line Business Practice Location Address:
PEDIATRICS
Provider Business Practice Location Address City Name:
ALBANY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12208-2248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-525-2445
Provider Business Practice Location Address Fax Number:
518-475-7069
Provider Enumeration Date:
06/06/2006

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: 363LP0200X , with the licence number:  F380750 , 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: 01878459 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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