Basic Information
| Provider Information | |||||||||
| NPI: | 1346277399 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THIEDE | ||||||||
| FirstName: | STEPHAN | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416877134 | ||||||||
| FaxNumber: | 5416877135 | ||||||||
| Practice Location | |||||||||
| Address1: | 1255 HILYARD ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416877134 | ||||||||
| FaxNumber: | 5416877135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | MD25991 | OR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 8427338 | 05 | WA | MEDICAID | 269934 | 05 | OR | MEDICAID | MD9882R | 05 | AK | MEDICAID | MD4882R | 05 | AK | MEDICAID |