Provider Demographics
NPI:1871048462
Name:BENJAMIN C. DICKERT
Entity type:Organization
Organization Name:BENJAMIN C. DICKERT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DICKERT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:413-736-3225
Mailing Address - Street 1:780 CHESTNUT ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1637
Mailing Address - Country:US
Mailing Address - Phone:413-736-3225
Mailing Address - Fax:413-736-3382
Practice Address - Street 1:780 CHESTNUT ST
Practice Address - Street 2:SUITE 8
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1637
Practice Address - Country:US
Practice Address - Phone:413-736-3225
Practice Address - Fax:413-736-3382
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENJAMIN DICKERT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1884213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY78037Medicare PIN