Provider Demographics
NPI:1154647071
Name:NEUDECKER, MAGGIE BETH (MD)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:BETH
Last Name:NEUDECKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4570 CTY. HWY. 61
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767-9401
Mailing Address - Country:US
Mailing Address - Phone:218-485-4491
Mailing Address - Fax:218-485-4724
Practice Address - Street 1:4570 CTY. HWY. 61
Practice Address - Street 2:
Practice Address - City:MOOSE LAKE
Practice Address - State:MN
Practice Address - Zip Code:55767-9401
Practice Address - Country:US
Practice Address - Phone:218-485-4491
Practice Address - Fax:218-485-4724
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN54207207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154647071OtherMEDICA
P00978476OtherRR MEDICARE
MN1154647071Medicaid
MN1154647071OtherBCBS OF MN
MN1154647071Medicaid