Provider Demographics
NPI:1376597401
Name:DIBERT & NUTT MD PA
Entity Type:Organization
Organization Name:DIBERT & NUTT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:DIBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-864-5550
Mailing Address - Street 1:2555 COURT DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2134
Mailing Address - Country:US
Mailing Address - Phone:704-864-5550
Mailing Address - Fax:704-864-7448
Practice Address - Street 1:2555 COURT DR
Practice Address - Street 2:SUITE 400
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2134
Practice Address - Country:US
Practice Address - Phone:704-864-5550
Practice Address - Fax:704-864-7448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC28459OtherBLUE CROSS BLUE SHIELD
NC5902832Medicaid
NC22658OtherPARTNERS MEDICARE
NC8928459Medicaid
NC28459OtherBLUE CROSS BLUE SHIELD
NC2349563Medicare ID - Type UnspecifiedGRP#
NC8928459Medicaid