Kenneth Anthony Dietrich, M.D., MBA
Individual provider Active NPI Pediatric Critical Care Medicine Physician · Elma, WA
NPI 1245288752 · NPPES record last updated Apr 4, 2019
Key facts
- NPI
- 1245288752
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatric Critical Care Medicine Physician 2080P0203X
- License
- 27133 (WA)
- Practice address
- 600 E Main St
Elma, WA 98541-9560 - Phone
- (360) 346-2240
- Fax
- (360) 346-2192
- NPI assigned
- May 5, 2006
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 2
Owned or controlled facilities with NPI records 3
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
All facility ownership & control disclosures 3
| Facility | Type | Role | Since |
|---|---|---|---|
| Summit Pacific Medical Center - Swing Bed Unit |
Hospital | Corporate Officer (75%) | Mar 22, 2018 |
| McCleary Healthcare Clinic |
Rural health clinic | Corporate Officer (10%) | Dec 1, 2016 |
| Summit Pacific Health Clinic |
Rural health clinic | Corporate Officer | Mar 24, 2016 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050623000139 | WA | Practitioner - Pediatric Medicine |
1658275482 | Reassigns benefits to 2 organizations |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Master of Business Administration, Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 27133 | WA | MD | Pediatric Critical Care Medicine Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Grays Harbor County Public Hospital District No 1 | Current |
Accepting new patients | |
| Grays Harbor County Public Hospital District No 1 | Current |
Accepting new patients |
Locations
600 E Main St
Elma, WA 98541
Phone (360) 346-2222
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatric Critical Care Medicine Physician | 2080P0203X | 27133 | WA | Yes |
Addresses
Primary practice location
600 E Main St
Elma, WA 98541-9560
Mailing address
600 E Main St
Elma, WA 98541-9560
Phone (360) 346-2240
Other practice location 1
314 Martin Luther King Jr Way
Suite 9
Tacoma, WA 98405-4250
Phone (253) 403-1511
Other providers in Elma, WA
- Sean Garland Cherry
- Jennie Coic
- Columbia Capital Medical Center, LP
- Kristi Lynn Covey
- Zoe Daee
- Kristin Rain Dineen
- Stephen L Drasnin
- East Grays Harbor Fire and Rescue
- Edwards & Ketcher, PLLC
- Karissa Ann Ellis
All providers in Elma, WA · Pediatric Critical Care Medicine Physician in Washington
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 4, 2019. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.