MEDICARE: BRIAN THIENEMANN MACDOWELL 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	30836	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0171620	OTHER	NC	UHC
3	53676	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1417911835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN THIENEMANN MACDOWELL MD

Provider Business Mailing Address
First Line	:	4724 DOVER ST NE
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33703-4126
Country	:	US
Telephone Number	:	828-778-8666
Fax Number	:

Provider Business Practice Location Address
First Line	:	4724 DOVER ST NE
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33703-4126
Country	:	US
Telephone Number	:	828-778-8666
Fax Number	:

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

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	12/19/2019

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