Healthcare Provider Details

I. General information

NPI: 1073569745
Provider Name (Legal Business Name): ANN H THEDIECK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 UINTA DR
GREEN RIVER WY
82935-5046
US

IV. Provider business mailing address

PO BOX 219
GREEN RIVER WY
82935-0219
US

V. Phone/Fax

Practice location:
  • Phone: 307-872-4500
  • Fax: 307-872-4595
Mailing address:
  • Phone: 307-872-4500
  • Fax: 307-872-4595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6716A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: