Basic Information
Provider Information | |||||||||
NPI: | 1861574279 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIBBY | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | ANTHONY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, FACP, CMD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 151 FRIES MILL RD | ||||||||
Address2: | SUITE 301 | ||||||||
City: | TURNERSVILLE | ||||||||
State: | NJ | ||||||||
PostalCode: | 080122016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563741881 | ||||||||
FaxNumber: | 8563021961 | ||||||||
Practice Location | |||||||||
Address1: | 151 FRIES MILL RD | ||||||||
Address2: | SUITE 301 | ||||||||
City: | TURNERSVILLE | ||||||||
State: | NJ | ||||||||
PostalCode: | 080122016 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563741881 | ||||||||
FaxNumber: | 8563021961 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 01/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MA58280 | NJ | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | P00887089 | 01 |   | RAILROAD MEDICARE (PALMETTO) | OTHER | 6310001 | 05 | NJ |   | MEDICAID | 0742942000 | 01 |   | AMERIHEALTH | OTHER |