Basic Information
| Provider Information | |||||||||
| NPI: | 1679669675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIEBACH | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | HENRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HOSPITAL PLZ | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069023602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032767485 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 HOSPITAL PLZ | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069023602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032767485 | ||||||||
| FaxNumber: | 2032767368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 01/17/2019 | ||||||||
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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 | 207R00000X | 154404 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 28139 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02490095 | 05 | NY | MEDICAID |