Provider Demographics
NPI:1598793101
Name:SIBERRY, GEORGE KELLY (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:KELLY
Last Name:SIBERRY
Suffix:
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 1:200 W 60TH ST APT 23H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-8508
Mailing Address - Country:US
Mailing Address - Phone:240-401-3685
Mailing Address - Fax:
Practice Address - Street 1:789 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1304
Practice Address - Country:US
Practice Address - Phone:203-688-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT61686208000000X, 2080P0208X
NY3130962080P0208X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1598793101Medicaid
MDKR47G294Medicare ID - Type Unspecified