Provider Demographics
NPI:1063415669
Name:KRUMDIECK, RICHARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:KRUMDIECK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 MEDICAL PARK RD
Mailing Address - Street 2:STE 101
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8540
Mailing Address - Country:US
Mailing Address - Phone:704-799-3946
Mailing Address - Fax:704-799-3956
Practice Address - Street 1:170 MEDICAL PARK ROAD
Practice Address - Street 2:STE 101
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8524
Practice Address - Country:US
Practice Address - Phone:704-799-3946
Practice Address - Fax:704-799-3956
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-27
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701019207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10907OtherBCBS
NC8910907Medicaid
E20805Medicare UPIN
10907OtherBCBS