Basic Information
| Provider Information | |||||||||
| NPI: | 1619081122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIEBURTZ | ||||||||
| FirstName: | KARL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 278984 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853417500 | ||||||||
| FaxNumber: | 5853417510 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 WESTFALL RD | ||||||||
| Address2: | BLDG C, SUITE 220 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853417500 | ||||||||
| FaxNumber: | 5853417510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
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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 | 2084N0400X | 164140 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 01259425 | 05 | NY | MEDICAID |