Provider Demographics
NPI:1972505915
Name:DIETRICH, ANN MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD FL 1
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-7899
Practice Address - Fax:864-455-5474
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC86478207PP0204X, 2080P0204X
OH350550792080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2028273Medicaid
WV0105570000Medicaid
KY6486614800Medicaid
SCPENDINGMedicaid
E68315Medicare UPIN