1205369253 NPI number — IVANIA TRINIDAD IRBY M.D.

Table of content: IVANIA TRINIDAD IRBY M.D. (NPI 1205369253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205369253 NPI number — IVANIA TRINIDAD IRBY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRBY
Provider First Name:
IVANIA
Provider Middle Name:
TRINIDAD
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROMERO VANEGAS
Provider Other First Name:
IVANIA
Provider Other Middle Name:
TRINIDAD
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205369253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
380 HOSPITAL DR
Provider Second Line Business Mailing Address:
BLDG A, STE 320
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31217-8001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-742-5331
Provider Business Mailing Address Fax Number:
833-355-1139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
380 HOSPITAL DR
Provider Second Line Business Practice Location Address:
BLDG A, STE 430
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31217-8001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-751-0366
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2017

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: 2084P0800X , with the licence number:  83836 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 117174800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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