MEDICARE: DAVID IMMANUEL THICKMAN 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	2085R0202X	Diagnostic Radiology Physician	DR28103	CO

General Provider Information

NPI Number	:	1689650939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID IMMANUEL THICKMAN MD

Provider Business Mailing Address
First Line	:	11995 SINGLETREE LANE, STE 500
Second Line	:
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55344-5349
Country	:	US
Telephone Number	:	952-595-1301
Fax Number	:	612-294-4903

Provider Business Practice Location Address
First Line	:	109 SOPRIS MESA DR
Second Line	:
City	:	CARBONDALE
State	:	CO
Zip	:	81623-3150
Country	:	US
Telephone Number	:	952-595-1100
Fax Number	:	612-294-4903

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

Provider Enumeration Date	:	12/19/2005
Last Update Date	:	05/30/2017

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