Provider Demographics
NPI:1417911835
Name:MACDOWELL, BRIAN THIENEMANN (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THIENEMANN
Last Name:MACDOWELL
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 1:4724 DOVER ST NE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-4126
Mailing Address - Country:US
Mailing Address - Phone:828-778-8666
Mailing Address - Fax:
Practice Address - Street 1:4724 DOVER ST NE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-4126
Practice Address - Country:US
Practice Address - Phone:828-778-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30836207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8953676Medicaid
NC0171620OtherUHC
NC53676OtherBCBS
NC208413BMedicare ID - Type Unspecified
NC8953676Medicaid