Healthcare Provider Details

I. General information

NPI: 1568557239
Provider Name (Legal Business Name): EWING TIBBELS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 E BEAVER AVE
STATE COLLEGE PA
16801-5633
US

IV. Provider business mailing address

PO BOX 592
CLEARFIELD PA
16830-0592
US

V. Phone/Fax

Practice location:
  • Phone: 814-339-7101
  • Fax: 814-339-6165
Mailing address:
  • Phone: 814-339-7101
  • Fax: 814-339-6165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD026959L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: