MEDICARE: MISS MARIA E DIERCKS PT

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	225100000X	Physical Therapist	40QA00591400	NJ

General Provider Information

NPI Number	:	1215263504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS MARIA E DIERCKS PT

Provider Business Mailing Address
First Line	:	30-55 82 STREET
Second Line	:
City	:	EAST ELMHURST
State	:	NY
Zip	:	11370
Country	:	US
Telephone Number	:	917-617-8881
Fax Number	:

Provider Business Practice Location Address
First Line	:	85 ORIENT WAY
Second Line	:
City	:	RUTHERFORD
State	:	NJ
Zip	:	07070-2070
Country	:	US
Telephone Number	:	201-438-6266
Fax Number	:

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

Provider Enumeration Date	:	10/22/2009
Last Update Date	:	10/22/2009

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Directions to “ MISS MARIA E DIERCKS PT” Practice Location

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