Provider Demographics
NPI:1366605149
Name:TIEDEMANN, JULIAH C (MD)
Entity type:Individual
Prefix:DR
First Name:JULIAH
Middle Name:C
Last Name:TIEDEMANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JULIAH
Other - Middle Name:C
Other - Last Name:HUNTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3801 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5210
Practice Address - Country:US
Practice Address - Phone:417-269-6583
Practice Address - Fax:417-269-6573
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008006549207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO204497507Medicaid