1013011378 NPI number — DALE F. DIERBERG, MD

Table of content: (NPI 1013011378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013011378 NPI number — DALE F. DIERBERG, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DALE F. DIERBERG, MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013011378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2753 AUTUMN RUN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTERFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63005-7030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-227-6839
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 WEST 18TH STREET
Provider Second Line Business Practice Location Address:
DEPT. OF RADIOLOGY
Provider Business Practice Location Address City Name:
HERMANN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-486-2191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIERBERG
Authorized Official First Name:
DALE
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
636-227-6839

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10108 . This is a "HELATHCARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 784 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 10108 . This is a "HEALTHCARE USA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 8076 . This is a "GROUP HEALTH PLAN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 3079111 . This is a "CIGNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: NO ID UNDER INDIVIDU , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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