Provider Demographics
NPI:1568039519
Name:DIEM, ADAM DOUGLAS
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:DOUGLAS
Last Name:DIEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-4204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5806 CHURCH LN
Practice Address - Street 2:
Practice Address - City:HYDES
Practice Address - State:MD
Practice Address - Zip Code:21082-9722
Practice Address - Country:US
Practice Address - Phone:443-604-2530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212608367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered