1427464411 NPI number — DR. AMELIA BLAINE SYBENGA D.O.

Table of content: DR. AMELIA BLAINE SYBENGA D.O. (NPI 1427464411)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427464411 NPI number — DR. AMELIA BLAINE SYBENGA D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SYBENGA
Provider First Name:
AMELIA
Provider Middle Name:
BLAINE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1427464411
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 S 31ST ST
Provider Second Line Business Mailing Address:
DEPARTMENT OF PATHOLOGY, RM 261B
Provider Business Mailing Address City Name:
TEMPLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76508-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-724-2435
Provider Business Mailing Address Fax Number:
254-724-4391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 COLCHESTER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401-1473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-847-0000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/10/2014

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: 207ZP0102X , with the licence number:  BP10047230 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 032-0133860 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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