Provider Demographics
NPI:1073570933
Name:TIBERIO, RICHARD A SR (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:A
Last Name:TIBERIO
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 MORRELL AVE
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-3959
Mailing Address - Country:US
Mailing Address - Phone:724-603-3496
Mailing Address - Fax:724-603-3498
Practice Address - Street 1:1064 MORRELL AVE
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-3959
Practice Address - Country:US
Practice Address - Phone:724-603-3496
Practice Address - Fax:724-603-3498
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025861E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009124210002Medicaid
428118Medicare ID - Type Unspecified
PA0009124210002Medicaid