Basic Information
| Provider Information | |||||||||
| NPI: | 1497759807 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIETZ | ||||||||
| FirstName: | BERNHARD | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383402231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319890001 | ||||||||
| FaxNumber: | 7315200064 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383402231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7318242400 | ||||||||
| FaxNumber: | 7318240388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2005 | ||||||||
| LastUpdateDate: | 02/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27623 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3077257 | 01 | TN | BC/BS OF TENNESSEE | OTHER | 7864 | 01 | TN | TLC-MEMPHIS MANAGED CARE | OTHER | 3818356 | 05 | TN | MEDICAID | 80121733 | 01 | TN | METRAHEALTH | OTHER | 5572559 | 01 | TN | AETNA | OTHER |