Basic Information
| Provider Information | |||||||||
| NPI: | 1912953761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIBALLI | ||||||||
| FirstName: | GERARD | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 FOUNTAIN PLAZA | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142022211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166918838 | ||||||||
| FaxNumber: | 7162044501 | ||||||||
| Practice Location | |||||||||
| Address1: | 3980 SHERIDAN DR | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142261727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167292800 | ||||||||
| FaxNumber: | 7169292819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 10/16/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 176342 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01354049 | 05 | NY | MEDICAID |