MEDICARE: DIANE L DIETZEN MD

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	207R00000X	Internal Medicine Physician	MD044558E	PA
2	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician	249857	MA

General Provider Information

NPI Number	:	1578569828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE L DIETZEN MD

Provider Business Mailing Address
First Line	:	280 CHESTNUT ST
Second Line	:	1ST FL
City	:	SPRINGFIELD
State	:	MA
Zip	:	01199-1619
Country	:	US
Telephone Number	:	413-794-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	759 CHESTNUT ST
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01199-1619
Country	:	US
Telephone Number	:	413-794-8121
Fax Number	:	413-794-4054

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	07/16/2013

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