Basic Information
| Provider Information | |||||||||
| NPI: | 1427024736 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIBALDI | ||||||||
| FirstName: | LAURINE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027972163 | ||||||||
| FaxNumber: | 7025602928 | ||||||||
| Practice Location | |||||||||
| Address1: | 2350 W CHARLESTON BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891022149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027972163 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 11660 | NV | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 11660 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100507801 | 05 | NV | MEDICAID | 1427024736 | 05 | NV | MEDICAID |