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NPI Code Detail

MEDICARE: DR. ANN H THEDIECK MD

MEDICARE: DR. ANN H THEDIECK 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
1207Q00000XFamily Medicine Physician6716AWY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1313158OTHERWYBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1073569745
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. ANN H THEDIECK MD
Provider Business Mailing Address
First Line : PO BOX 219
Second Line :
City : GREEN RIVER
State : WY
Zip : 82935-0219
Country : US
Telephone Number : 307-872-4500
Fax Number : 307-872-4595
Provider Business Practice Location Address
First Line : 1400 UINTA DR
Second Line :
City : GREEN RIVER
State : WY
Zip : 82935-5046
Country : US
Telephone Number : 307-872-4500
Fax Number : 307-872-4595
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/25/2006
Last Update Date : 07/08/2007

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Directions to “ DR. ANN H THEDIECK MD” Practice Location

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