Healthcare Provider Details

I. General information

NPI: 1093337404
Provider Name (Legal Business Name): STEPHANIE ALICE HIBBARD DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE ALICE MORIARTY

II. Dates (important events)

Enumeration Date: 05/08/2020
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 HIGH ST STE 1
SPRINGFIELD MA
01105-1442
US

IV. Provider business mailing address

280 CHESTNUT ST FL 2
SPRINGFIELD MA
01199-0001
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-2515
  • Fax: 413-794-5673
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1014495
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: