MEDICARE: DALLAS DIEDERICH PA-C

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA00509	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
9	P01478958	OTHER	TX	RAIL ROAD MEDICARE
13	P01478957	OTHER	TX	RAIL ROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	75-0818167-048	OTHER	TX	TRICARE
3	75-1976930-005	OTHER	TX	TRICARE
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	75-0818167-044	OTHER	TX	TRICARE
6	75-0818167-015	OTHER	TX	TRICARE
7	752616977001	OTHER	TX	TRICARE
8	8689NN	OTHER	TX	BCBS
10	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
11	752616977002	OTHER	TX	TRICARE
12	8EW436	OTHER	TX	BCBS
14	75-2616977-001	OTHER		TRICARE
15	8N3412	OTHER	TX	BCBS
16	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
17	75-0818167-022	OTHER	TX	TRICARE
18	752616977028	OTHER	TX	TRICARE
19	8679NN	OTHER	TX	BCBS

NPI Number	:	1982729216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALLAS DIEDERICH PA-C

Provider Business Mailing Address
First Line	:	PO BOX 846098
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-6098
Country	:	US
Telephone Number	:	903-324-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	20208 STATE HIGHWAY 155 S
Second Line	:
City	:	FLINT
State	:	TX
Zip	:	75762-5600
Country	:	US
Telephone Number	:	903-825-6222
Fax Number	:

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

Provider Enumeration Date	:	03/19/2007
Last Update Date	:	08/07/2015