Provider Demographics
NPI:1205053824
Name:RICHARD G. DIETHELM, MD, PC
Entity type:Organization
Organization Name:RICHARD G. DIETHELM, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:DIETHELM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-836-9366
Mailing Address - Street 1:48 MEDICAL PARK DR E STE 351
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3467
Mailing Address - Country:US
Mailing Address - Phone:205-836-9366
Mailing Address - Fax:205-836-9367
Practice Address - Street 1:48 MEDICAL PARK DR E STE 351
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3467
Practice Address - Country:US
Practice Address - Phone:205-836-9366
Practice Address - Fax:205-836-9367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL263602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDG1281OtherRAILROAD MEDICARE
AL529932807Medicaid
AL009910701Medicaid
ALDG1281OtherRAILROAD MEDICARE