Provider Demographics
NPI:1225194202
Name:DIEHL, ELISABETH ROSANNE (DO)
Entity Type:Individual
Prefix:DR
First Name:ELISABETH
Middle Name:ROSANNE
Last Name:DIEHL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:E.
Other - Middle Name:ROSANNE
Other - Last Name:DIEHL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:5576 GREENVILLE HWY 460
Mailing Address - City:ZIRCONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28790-0460
Mailing Address - Country:US
Mailing Address - Phone:864-915-3212
Mailing Address - Fax:
Practice Address - Street 1:600 N HIGHWAY 25
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-8208
Practice Address - Country:US
Practice Address - Phone:864-834-6652
Practice Address - Fax:864-834-6654
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97-00530207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCF88428OtherFORMER MEDICARE UPIN
SCOTH000Medicare UPIN