Provider Demographics
NPI:1811472616
Name:THEODORE TYBERG MD
Entity type:Organization
Organization Name:THEODORE TYBERG MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-850-6577
Mailing Address - Street 1:407 E 70TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5352
Mailing Address - Country:US
Mailing Address - Phone:646-850-6577
Mailing Address - Fax:646-998-5050
Practice Address - Street 1:407 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5327
Practice Address - Country:US
Practice Address - Phone:646-850-6577
Practice Address - Fax:646-998-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty