Provider Demographics
NPI:1952394132
Name:TIEDEMANN, RICHARD N (MD, FACS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:N
Last Name:TIEDEMANN
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 RAHWAY RD
Mailing Address - Street 2:
Mailing Address - City:SCOTCH PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07076-3412
Mailing Address - Country:US
Mailing Address - Phone:908-625-8036
Mailing Address - Fax:908-754-5904
Practice Address - Street 1:1100 RAHWAY RD
Practice Address - Street 2:
Practice Address - City:SCOTCH PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07076-3412
Practice Address - Country:US
Practice Address - Phone:908-625-8036
Practice Address - Fax:908-754-5904
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA2503965900208D00000X
NJ25MA03965900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJB83837Medicare UPIN