MEDICARE: DR. KEITH J DIETRICK M.D.

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	208VP0014X	Interventional Pain Medicine Physician	ME85786	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144223785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH J DIETRICK M.D.

Provider Business Mailing Address
First Line	:	2585 SOUTH STATE ROAD 7
Second Line	:	STE 110
City	:	WELLINGTON
State	:	FL
Zip	:	33414-9323
Country	:	US
Telephone Number	:	561-795-8655
Fax Number	:	561-795-3275

Provider Business Practice Location Address
First Line	:	2585 SOUTH STATE ROAD 7
Second Line	:	STE 110
City	:	WELLINGTON
State	:	FL
Zip	:	33414-9323
Country	:	US
Telephone Number	:	561-795-8655
Fax Number	:	561-795-3275

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	08/17/2015

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