Provider Demographics
NPI:1497786263
Name:SUBER, TARREZZ B
Entity Type:Individual
Prefix:MS
First Name:TARREZZ
Middle Name:B
Last Name:SUBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2153 MARGARET AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-2650
Mailing Address - Country:US
Mailing Address - Phone:614-975-7358
Mailing Address - Fax:614-251-4416
Practice Address - Street 1:2153 MARGARET AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-2650
Practice Address - Country:US
Practice Address - Phone:614-975-7358
Practice Address - Fax:614-251-4416
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2404188Medicaid