1063499127 NPI number — STEVEN R DIETERICH MD

Table of content: STEVEN R DIETERICH MD (NPI 1063499127)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063499127 NPI number — STEVEN R DIETERICH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIETERICH
Provider First Name:
STEVEN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1063499127
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 518
Provider Second Line Business Mailing Address:
13 CHURCH RD
Provider Business Mailing Address City Name:
EAST GRANBY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06026-0518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-653-4526
Provider Business Mailing Address Fax Number:
860-653-5209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13 CHURCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST GRANBY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06026-0518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-653-4526
Provider Business Practice Location Address Fax Number:
860-653-5209
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  018693 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 140065 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001186931 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010018693CT01 . This is a "BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0104402 . This is a "UNITED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 018693 . This is a "CT" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: HAP210 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 2085328005 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0P0372 . This is a "HEALTHNET" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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