1194702597 NPI number — PETER E DIEDRICHSEN M.D.

Table of content: PETER E DIEDRICHSEN M.D. (NPI 1194702597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194702597 NPI number — PETER E DIEDRICHSEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIEDRICHSEN
Provider First Name:
PETER
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1194702597
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1275
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBUS
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68602-1681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-563-3686
Provider Business Mailing Address Fax Number:
402-563-3084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3772 43RD AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
COLUMBUS
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68601-1681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-563-3686
Provider Business Practice Location Address Fax Number:
402-564-1797
Provider Enumeration Date:
12/27/2005

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: 207W00000X , with the licence number:  14980 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 47082635813 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01493 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( NE ) . This identifiers is of the category "OTHER".




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