Provider Demographics
NPI:1821024043
Name:DIBIASE, VIRGIL A (MD)
Entity Type:Individual
Prefix:
First Name:VIRGIL
Middle Name:A
Last Name:DIBIASE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 772988
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-2988
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:707 N MICHIGAN ST STE 102
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1068
Practice Address - Country:US
Practice Address - Phone:574-647-8542
Practice Address - Fax:574-647-8549
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042651A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
M32727008OtherMEDICARE
IN100386310Medicaid
IN90001130OtherILLINOIS BCBS
IN000000297220OtherANTHEM PIN
IN206230AMedicare ID - Type Unspecified