Provider Demographics
NPI:1750586780
Name:TERIBURY MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:TERIBURY MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:L
Authorized Official - Last Name:TERIBURY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:570-882-7401
Mailing Address - Street 1:114 DESMOND ST
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-2084
Mailing Address - Country:US
Mailing Address - Phone:570-882-7401
Mailing Address - Fax:570-882-7404
Practice Address - Street 1:114 DESMOND ST
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-2084
Practice Address - Country:US
Practice Address - Phone:570-882-7401
Practice Address - Fax:570-882-7404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427223174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI55985Medicare UPIN