Basic Information
| Provider Information | |||||||||
| NPI: | 1821314766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIERENBURG | ||||||||
| FirstName: | HIDA | ||||||||
| MiddleName: | DEL CARMEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BENERO RAMOS | ||||||||
| OtherFirstName: | HIDA | ||||||||
| OtherMiddleName: | DEL CARMEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1351 ROUTE 55 STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAGRANGEVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125405128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8454759661 | ||||||||
| FaxNumber: | 8454759938 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 READE PL STE 1100 | ||||||||
| Address2: | |||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452141922 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2010 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 65440 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 277380 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 04329677 | 05 | NY | MEDICAID |