MEDICARE: NICHOLAS TIBALDI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	19721	WV
2	207RG0100X	Gastroenterology Physician	35065820	OH
3	207RG0100X	Gastroenterology Physician	11661	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760478564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS TIBALDI M.D.

Provider Business Mailing Address
First Line	:	PO BOX 15645
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89114-5645
Country	:	US
Telephone Number	:	702-877-8330
Fax Number	:	702-877-8312

Provider Business Practice Location Address
First Line	:	2316 W CHARLESTON BLVD
Second Line	:	SUITE 280
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-2149
Country	:	US
Telephone Number	:	702-877-8330
Fax Number	:	702-877-8312

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2005
Last Update Date	:	02/14/2014

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Directions to “ NICHOLAS TIBALDI M.D.” Practice Location

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