1407977473 NPI number — JORG DIETRICH MD PHD

Table of content: JORG DIETRICH MD PHD (NPI 1407977473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407977473 NPI number — JORG DIETRICH MD PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DIETRICH
Provider First Name:
JORG
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD PHD
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:
1407977473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 BEACON ST
Provider Second Line Business Mailing Address:
APT 2A
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02116-1270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-722-3025
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
55 FRUIT STREET
Provider Second Line Business Practice Location Address:
YAWKEY CENTER 9E PAPPAS CENTER FOR NEUROONCOLOGY
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-724-8770
Provider Business Practice Location Address Fax Number:
617-724-8769
Provider Enumeration Date:
04/03/2007

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: 2084N0400X , with the licence number:  225271 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com