| NPI |
1982729216 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
| Entity Type Code |
1 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Provider Last Name Legal Name |
DIEDERICH |
The last name of the provider. If the provider is an individual, this is the legal name. |
| Provider First Name |
DALLAS |
The first name of the provider, if the provider
is an individual. |
| Provider Credential Text |
PA-C |
The abbreviations for professional degrees or credentials used or held by the provider,
if the provider is an individual. Examples
are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations
will not be verified by NPS. |
| Provider First Line Business Practice Location Address |
20208 STATE HIGHWAY 155 S |
The first line location address of the provider
being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box. |
| Provider Business Practice Location Address City Name |
FLINT |
The city name in the location address of the provider being identified. |
| Provider Business Practice Location Address State Name |
TX |
The State code in the location of the provider
being identified. |
| Provider Business Practice Location Address Postal Code |
757625600 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
| Provider Business Practice Location Address Telephone Number |
9038256222 |
The telephone number associated with the location address of the provider being identified. |
| Provider Enumeration Date |
3/19/2007 |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Last Update Date |
8/7/2015 |
The date that a record was last updated or changed. |
| Provider Gender Code |
M |
The code designating the provider’s gender if the provider is a person. |
| Healthcare Provider Taxonomy Code 1 |
363A00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Provider License Number 1 |
PA00509 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
| Provider License Number State Code 1 |
TX |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Other Provider Identifier 1 |
752616977001 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 1 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 1 |
TX |
|
| Other Provider Identifier Issuer 1 |
TRICARE |
|
| Other Provider Identifier 2 |
75-2616977-001 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 2 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Issuer 2 |
TRICARE |
|
| Other Provider Identifier 3 |
8EW436 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 3 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 3 |
TX |
|
| Other Provider Identifier Issuer 3 |
BCBS |
|
| Other Provider Identifier 4 |
75-0818167-048 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 4 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 4 |
TX |
|
| Other Provider Identifier Issuer 4 |
TRICARE |
|
| Other Provider Identifier 5 |
75-0818167-044 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 5 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 5 |
TX |
|
| Other Provider Identifier Issuer 5 |
TRICARE |
|
| Other Provider Identifier 6 |
75-1976930-005 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 6 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 6 |
TX |
|
| Other Provider Identifier Issuer 6 |
TRICARE |
|
| Other Provider Identifier 7 |
752616977028 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 7 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 7 |
TX |
|
| Other Provider Identifier Issuer 7 |
TRICARE |
|
| Other Provider Identifier 8 |
8679NN |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 8 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 8 |
TX |
|
| Other Provider Identifier Issuer 8 |
BCBS |
|
| Other Provider Identifier 9 |
202460601 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 9 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 9 |
TX |
|
| Other Provider Identifier 10 |
202460603 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 10 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 10 |
TX |
|
| Other Provider Identifier 11 |
P01478958 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 11 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 11 |
TX |
|
| Other Provider Identifier Issuer 11 |
RAIL ROAD MEDICARE |
|
| Other Provider Identifier 12 |
202460602 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 12 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 12 |
TX |
|
| Other Provider Identifier 13 |
202460604 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 13 |
05 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 13 |
TX |
|
| Other Provider Identifier 14 |
75-0818167-022 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 14 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 14 |
TX |
|
| Other Provider Identifier Issuer 14 |
TRICARE |
|
| Other Provider Identifier 15 |
8N3412 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 15 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 15 |
TX |
|
| Other Provider Identifier Issuer 15 |
BCBS |
|
| Other Provider Identifier 16 |
752616977002 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 16 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 16 |
TX |
|
| Other Provider Identifier Issuer 16 |
TRICARE |
|
| Other Provider Identifier 17 |
P01478957 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 17 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 17 |
TX |
|
| Other Provider Identifier Issuer 17 |
RAIL ROAD MEDICARE |
|
| Other Provider Identifier 18 |
75-0818167-015 |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 18 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 18 |
TX |
|
| Other Provider Identifier Issuer 18 |
TRICARE |
|
| Other Provider Identifier 19 |
8689NN |
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier Type Code 19 |
01 |
Code indicating the type of identifier currently
or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form. |
| Other Provider Identifier State 19 |
TX |
|
| Other Provider Identifier Issuer 19 |
BCBS |
|
| Is Sole Proprietor |
Y |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |