Healthcare Provider Details

I. General information

NPI: 1952394132
Provider Name (Legal Business Name): RICHARD N TIEDEMANN MD, FACS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 RAHWAY RD
SCOTCH PLAINS NJ
07076-3412
US

IV. Provider business mailing address

1100 RAHWAY RD
SCOTCH PLAINS NJ
07076-3412
US

V. Phone/Fax

Practice location:
  • Phone: 908-625-8036
  • Fax: 908-754-5904
Mailing address:
  • Phone: 908-625-8036
  • Fax: 908-754-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMA2503965900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA03965900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: