Provider Demographics
NPI:1952367989
Name:TIEDEMANN, MARIE THERESE (MD)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:THERESE
Last Name:TIEDEMANN
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 1:635 N WASHINGTON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-1317
Mailing Address - Country:US
Mailing Address - Phone:804-798-9208
Mailing Address - Fax:804-798-8108
Practice Address - Street 1:635 N WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-1317
Practice Address - Country:US
Practice Address - Phone:804-798-9208
Practice Address - Fax:804-798-8108
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035312207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC0574OtherGROUP PTAN
VA021877P95 - C03895Medicare PIN