Provider Demographics
NPI:1639323058
Name:GEORGE F. DIETZ, MD
Entity Type:Organization
Organization Name:GEORGE F. DIETZ, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:F
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-730-2920
Mailing Address - Street 1:212 S SCOVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3220
Mailing Address - Country:US
Mailing Address - Phone:773-730-2920
Mailing Address - Fax:708-386-3694
Practice Address - Street 1:212 S SCOVILLE AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-3220
Practice Address - Country:US
Practice Address - Phone:773-730-2920
Practice Address - Fax:708-386-3694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036037099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL496790Medicare PIN
ILD13239Medicare UPIN