Provider Demographics
NPI:1760846257
Name:SIEBURTH, REBECCA MCNEILL (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:MCNEILL
Last Name:SIEBURTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 TROY SCHENECTADY RD
Mailing Address - Street 2:STE 218
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2490
Mailing Address - Country:US
Mailing Address - Phone:212-523-4000
Mailing Address - Fax:
Practice Address - Street 1:1111 AMSTERDAM AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1716
Practice Address - Country:US
Practice Address - Phone:212-523-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302187207W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty