Provider Demographics
NPI:1033182555
Name:THIESSEN, MARY L (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:THIESSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 78009
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63178-8009
Mailing Address - Country:US
Mailing Address - Phone:866-898-7142
Mailing Address - Fax:616-975-9824
Practice Address - Street 1:4000 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-3220
Practice Address - Country:US
Practice Address - Phone:913-588-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34029207P00000X
MO2006014613207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200414090AMedicaid
KS200414090DMedicaid
37400018OtherBCBS
MO2004140908Medicaid
MO200226405Medicaid
431832147A061OtherCHAMPUS
P00393445OtherRAILROAD MEDICARE
KS200414090CMedicaid
AZ952855Medicaid