Basic Information
| Provider Information | |||||||||
| NPI: | 1598793101 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIBERRY | ||||||||
| FirstName: | GEORGE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036885555 | ||||||||
| FaxNumber: | 2036884516 | ||||||||
| Practice Location | |||||||||
| Address1: | 789 HOWARD AVE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036885555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 03/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 61686 | CT | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0208X | 61686 | CT | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | 1598793101 | 05 | CT | MEDICAID |