MEDICARE: DR. ANNIE L IDEKER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	48491	MN

General Provider Information

NPI Number	:	1891775847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANNIE L IDEKER MD

Provider Business Mailing Address
First Line	:	8170 33RD AVE S
Second Line	:	MS21110Q
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55425-4516
Country	:	US
Telephone Number	:	952-883-5375
Fax Number	:	651-523-8584

Provider Business Practice Location Address
First Line	:	3930 NORTHWOODS DR - MAIL STOP 32800A
Second Line	:	HEALTHPARTNERS ARDEN HILLS CLINIC
City	:	ARDEN HILLS
State	:	MN
Zip	:	55112-6974
Country	:	US
Telephone Number	:	651-523-8500
Fax Number	:	651-523-8584

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	12/01/2011

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