1548296221 NPI number — COLLEEN M DIBBLE MD

Table of content: COLLEEN M DIBBLE MD (NPI 1548296221)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548296221 NPI number — COLLEEN M DIBBLE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIBBLE
Provider First Name:
COLLEEN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRUMLISH
Provider Other First Name:
COLLEEN
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1548296221
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 MCCLELLAN ST
Provider Second Line Business Mailing Address:
SUITE G02
Provider Business Mailing Address City Name:
SCHENECTADY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12304-1020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-382-2203
Provider Business Mailing Address Fax Number:
518-382-2226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 MCCLELLAN ST
Provider Second Line Business Practice Location Address:
SUITE G02
Provider Business Practice Location Address City Name:
SCHENECTADY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12304-1020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-382-2203
Provider Business Practice Location Address Fax Number:
518-382-2226
Provider Enumeration Date:
06/24/2006

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: 207R00000X , with the licence number:  263695 , 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: 755CJ1 . This is a "EMPIRE BLUECROSS/BLUESHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7367465 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 130603000000 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 03561199 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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