Provider Demographics
NPI:1013011378
Name:DALE F. DIERBERG, MD
Entity Type:Organization
Organization Name:DALE F. DIERBERG, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:F
Authorized Official - Last Name:DIERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:636-227-6839
Mailing Address - Street 1:2753 AUTUMN RUN CT
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-7030
Mailing Address - Country:US
Mailing Address - Phone:636-227-6839
Mailing Address - Fax:
Practice Address - Street 1:509 WEST 18TH STREET
Practice Address - Street 2:DEPT. OF RADIOLOGY
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041
Practice Address - Country:US
Practice Address - Phone:573-486-2191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-08
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO10108OtherHELATHCARE USA
MO784OtherBCBS
MO10108OtherHEALTHCARE USA
MO8076OtherGROUP HEALTH PLAN
MO3079111OtherCIGNA
MONO ID UNDER INDIVIDUMedicaid
MO10108OtherHEALTHCARE USA