Healthcare Provider Details

I. General information

NPI: 1801327788
Provider Name (Legal Business Name): JAMES D DIETERICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3122 N ASHLAND AVE
CHICAGO IL
60657-3014
US

IV. Provider business mailing address

3122 N ASHLAND AVE
CHICAGO IL
60657-3014
US

V. Phone/Fax

Practice location:
  • Phone: 773-687-7000
  • Fax: 773-687-7795
Mailing address:
  • Phone: 773-687-7000
  • Fax: 773-687-7795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number036161687
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: