Provider Demographics
NPI:1891784757
Name:DEWEESE, FREDERICK THANE (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:THANE
Last Name:DEWEESE
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 1:510 LINCOLN DRIVE
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948
Mailing Address - Country:US
Mailing Address - Phone:618-997-6800
Mailing Address - Fax:618-997-1187
Practice Address - Street 1:4787 ALBEN BARKLEY DRIVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42002
Practice Address - Country:US
Practice Address - Phone:270-442-9461
Practice Address - Fax:270-441-0079
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36333207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64028889Medicaid
KY0097310Medicare Oscar/Certification