Basic Information
| Provider Information | |||||||||
| NPI: | 1073664033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEURSING | ||||||||
| FirstName: | DIEDERIK | ||||||||
| MiddleName: | FREDERIK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 PLEASANT ST APT 8-1 | ||||||||
| Address2: | |||||||||
| City: | WESTFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018862376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186160398 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 326 NICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | FITCHBURG | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014201914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9788788100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2007 | ||||||||
| LastUpdateDate: | 08/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 24935 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 04-41597 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 24935 | OK | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 246721 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200174480A | 05 | OK | MEDICAID |