Provider Demographics
NPI:1861545188
Name:CHARLES L. DIETZEK
Entity type:Organization
Organization Name:CHARLES L. DIETZEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-309-9777
Mailing Address - Street 1:1000 WHITE HORSE RD
Mailing Address - Street 2:SUITE 703
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4406
Mailing Address - Country:US
Mailing Address - Phone:856-309-9777
Mailing Address - Fax:
Practice Address - Street 1:543 EGG HARBOR RD
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-2335
Practice Address - Country:US
Practice Address - Phone:856-256-2063
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2417720000OtherAMERIHEALTH
NJ0071641Medicaid
NJ3947376OtherAETNA
NJ0071641Medicaid