=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396935243
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAUL H. NIEBERG, M.D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2007
-----------------------------------------------------
Last Update Date | 10/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 960 E GREEN ST STE 105
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91106-2443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-304-0782
-----------------------------------------------------
Fax | 626-658-2848
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1449
-----------------------------------------------------
City | BREA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92822-1449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-996-1633
-----------------------------------------------------
Fax | 714-996-9267
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PAUL HENRY NIEBERG
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 626-584-1341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | A67350
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------