Basic Information
Provider Information | |||||||||
NPI: | 1891796868 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DICKMEYER | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1234 E DUPONT RD | ||||||||
Address2: | SUITE 3 | ||||||||
City: | FORT WAYNE | ||||||||
State: | IN | ||||||||
PostalCode: | 468251545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2603739700 | ||||||||
FaxNumber: | 2603739740 | ||||||||
Practice Location | |||||||||
Address1: | 1270 E STATE ROAD 205 | ||||||||
Address2: | SUITE 240 | ||||||||
City: | COLUMBIA CITY | ||||||||
State: | IN | ||||||||
PostalCode: | 467259499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2602447600 | ||||||||
FaxNumber: | 2602445212 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2005 | ||||||||
LastUpdateDate: | 09/24/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 03/22/2006 | ||||||||
NPIReactivationDate: | 03/30/2006 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01029443 | IN | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 351972384039 | 01 | IN | TRICARE | OTHER | P00467073 | 01 | IN | RAILROAD MEDICAE | OTHER | 3937240025 | 01 | IN | MEDICARE DMEPOS | OTHER | 1229 | 01 | IN | PHP | OTHER | 100263110A | 05 | IN |   | MEDICAID | 000000325785 | 01 | IN | ANTHEM | OTHER | 000000570550 | 01 | IN | ANTHEM | OTHER | 1977073 | 01 | IN | CIGNA | OTHER | 4048678 | 01 | IN | AETNA | OTHER |