Healthcare Provider Details

I. General information

NPI: 1063403905
Provider Name (Legal Business Name): CHRISTOPHER T DIETRICH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 5TH ST
RAPID CITY SD
57701-6021
US

IV. Provider business mailing address

PO BOX 6850
RAPID CITY SD
57709-6850
US

V. Phone/Fax

Practice location:
  • Phone: 605-341-1414
  • Fax: 605-341-7062
Mailing address:
  • Phone:
  • Fax: 605-341-7062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number5661
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5661
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: