Provider Demographics
NPI:1386840478
Name:DIETRICH, ANNE ELISABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNE
Middle Name:ELISABETH
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANNE
Other - Middle Name:ELISABETH
Other - Last Name:MODRZYNSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-5000
Mailing Address - Fax:
Practice Address - Street 1:1601 SAINT FRANCIS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-3383
Practice Address - Country:US
Practice Address - Phone:952-428-3535
Practice Address - Fax:952-428-3599
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR8178208600000X
MN55051208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20003278Medicare PIN