Provider Demographics
NPI:1346277399
Name:THIEDE, STEPHAN G (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:G
Last Name:THIEDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 HARLOW RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1341
Mailing Address - Country:US
Mailing Address - Phone:541-302-7771
Mailing Address - Fax:
Practice Address - Street 1:1200 HILYARD ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8122
Practice Address - Country:US
Practice Address - Phone:541-687-7134
Practice Address - Fax:541-687-7135
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD259912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269934Medicaid
AKMD4882RMedicaid
AKMD9882RMedicaid
WA8427338Medicaid
OR131707Medicare PIN
WA8427338Medicaid
AKMD4882RMedicaid
OR269934Medicaid
ORP00232530Medicare PIN
AK161141Medicare PIN
ORP00384400Medicare PIN
ORP00256521Medicare PIN