MEDICARE: MR. EBERHARDT ALAN DIETZEL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1689435026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EBERHARDT ALAN DIETZEL

Provider Business Mailing Address
First Line	:	1006 QUINCY ST
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1829
Country	:	US
Telephone Number	:	920-559-8808
Fax Number	:

Provider Business Practice Location Address
First Line	:	1006 QUINCY ST
Second Line	:
City	:	STURGEON BAY
State	:	WI
Zip	:	54235-1829
Country	:	US
Telephone Number	:	920-559-8808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2024
Last Update Date	:	01/22/2024

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