Basic Information
Provider Information | |||||||||
NPI: | 1295744910 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HARBECK | ||||||||
FirstName: | TARA | ||||||||
MiddleName: | NOREEN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GORMAN | ||||||||
OtherFirstName: | TARA | ||||||||
OtherMiddleName: | NOREEN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPM | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 99 E STATE ST | ||||||||
Address2: | PO BOX 1250 | ||||||||
City: | GLOVERSVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 120781203 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188838620 | ||||||||
FaxNumber: | 5188835653 | ||||||||
Practice Location | |||||||||
Address1: | 4104 STATE HIGHWAY 30 | ||||||||
Address2: |   | ||||||||
City: | PERTH | ||||||||
State: | NY | ||||||||
PostalCode: | 120100000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5188838862 | ||||||||
FaxNumber: | 5188835653 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/05/2006 | ||||||||
LastUpdateDate: | 01/21/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | N005812 | NY | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 02195935 | 05 | NY |   | MEDICAID |