1265549760 NPI number — JENNIFER L THIE MD

Table of content: JENNIFER L THIE MD (NPI 1265549760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265549760 NPI number — JENNIFER L THIE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIE
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265549760
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11595 N MERIDIAN ST STE 375
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARMEL
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46032-3950
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-575-7304
Provider Business Mailing Address Fax Number:
317-575-7333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10506 MONTGOMERY RD STE 504
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45242-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-922-0009
Provider Business Practice Location Address Fax Number:
513-931-2481
Provider Enumeration Date:
08/23/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207VE0102X , with the licence number:  35042512T , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VG0400X , with the licence number: 35042512T , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0218740 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".