Healthcare Provider Details

I. General information

NPI: 1730455783
Provider Name (Legal Business Name): MICHAEL TYBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE MAIMONIDES MEDICAL CENTER
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

1719 E 7TH ST
BROOKLYN NY
11223-2215
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-6000
  • Fax:
Mailing address:
  • Phone: 718-902-5530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number281363
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: