Provider Demographics
NPI:1023063674
Name:TEBBEN, ROBERT BATES (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BATES
Last Name:TEBBEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201
Mailing Address - Country:US
Mailing Address - Phone:413-447-2752
Mailing Address - Fax:413-496-6836
Practice Address - Street 1:777 NORTH ST
Practice Address - Street 2:CARDIOLOGY
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201
Practice Address - Country:US
Practice Address - Phone:413-395-7580
Practice Address - Fax:413-499-8539
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1852363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q20815Medicare UPIN
AP2185Medicare ID - Type Unspecified