Basic Information
| Provider Information | |||||||||
| NPI: | 1336129527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIETRICK | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 COTTMAN AVENUE | ||||||||
| Address2: | MEDICAL STAFF OFFICE/ENROLLMENT | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 19111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157286900 | ||||||||
| FaxNumber: | 2152141425 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 COTTMAN AVENUE | ||||||||
| Address2: | FOX CHASE CANCER CENTER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2157286900 | ||||||||
| FaxNumber: | 2152141425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 03/03/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD031249E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1180600 | 05 | PA | MEDICAID |