Basic Information
| Provider Information | |||||||||
| NPI: | 1497792170 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DICKRIEDE | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 E OAKMONT WAY | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440672796 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20000 HARVARD AVE | ||||||||
| Address2: | |||||||||
| City: | WARRENSVILLE HEIGHTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441226805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164916000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 34004386 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00319998 | 01 | OH | MEDICARE TRAVELERS RR-GA | OTHER | 0739982 | 05 | OH | MEDICAID | 942460636464 | 01 | OH | CARESOURCE | OTHER |