Provider Demographics
NPI:1922393891
Name:KIERAS-SKIBA, MARIE A (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:A
Last Name:KIERAS-SKIBA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:A
Other - Last Name:KIERAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:55 LAKE AVE N
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01655-0002
Mailing Address - Country:US
Mailing Address - Phone:508-334-1000
Mailing Address - Fax:
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-18
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA248625208000000X
CT541752080A0000X
CT054175207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine