Provider Demographics
NPI:1922062520
Name:OVERHOLT-THIESEN, SHELLEY D (MD)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:D
Last Name:OVERHOLT-THIESEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:320 EAST MAIN STREET
Practice Address - Street 2:CUYUNA REGIONAL MEDICAL CENTER
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-29239207Q00000X
MN57858207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN57858OtherMN LICENSE
KS100404310AMedicaid
KS101306Medicare ID - Type UnspecifiedMEDICARE INDIV NUMBER
KS100404310AMedicaid