Basic Information
| Provider Information | |||||||||
| NPI: | 1750387643 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DERICK | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5300 HARROUN RD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198241100 | ||||||||
| FaxNumber: | 4198241771 | ||||||||
| Practice Location | |||||||||
| Address1: | 5300 HARROUN RD | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | SYLVANIA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435602182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4198241100 | ||||||||
| FaxNumber: | 4198241771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2005 | ||||||||
| LastUpdateDate: | 03/18/2014 | ||||||||
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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 | 207V00000X | 35044704 | OH | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 000000142525 | 01 | OH | ANTHEM | OTHER | 344428256 | 01 | CA | BEECH STREET | OTHER | 000000385212 | 01 | OH | ANTHEM COMMERICAL | OTHER | 0458802 | 05 | OH | MEDICAID | 344428256 | 01 | OH | EMERALD | OTHER | 4002382 | 01 | OH | AETNA | OTHER | 142491 | 01 | MI | PRIORITY HEALTH | OTHER | PH00240649 | 01 | OH | NATIONWIDE | OTHER | 4826635 | 05 | MI | MEDICAID | 2974411950-006 | 01 | OH | MEDICAL MUTUAL | OTHER | 0000004002383 | 01 | OH | ANTHEM MEDICAID | OTHER | 142491 | 01 | OH | CARE CHOICES | OTHER | 8081472 | 01 | OH | CIGNA | OTHER |