Basic Information
| Provider Information | |||||||||
| NPI: | 1336111038 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEBHARD | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 CARDINAL LN | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140721950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166490887 | ||||||||
| FaxNumber: | 7166464611 | ||||||||
| Practice Location | |||||||||
| Address1: | 621 10TH ST | ||||||||
| Address2: | |||||||||
| City: | NIAGARA FALLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 143011813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 176365 | NY | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 01607583 | 05 | NY | MEDICAID |