Provider Demographics
NPI:1447436266
Name:DIERCKMAN, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:DIERCKMAN
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 1:2004 HAYES ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2689
Mailing Address - Country:US
Mailing Address - Phone:615-324-1600
Mailing Address - Fax:615-324-1661
Practice Address - Street 1:2004 HAYES ST STE 200
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2689
Practice Address - Country:US
Practice Address - Phone:818-901-6600
Practice Address - Fax:818-997-7826
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN59630207X00000X
IN01071470A207X00000X
CAA115842207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201086420Medicaid
IN201086420Medicaid
CAFG867ZMedicare UPIN