Provider Demographics
NPI:1386634046
Name:THIEMANN, MARK WALTER (PAC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WALTER
Last Name:THIEMANN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 MERCY HEALTH BLVD STE 450
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-1106
Mailing Address - Country:US
Mailing Address - Phone:513-347-9999
Mailing Address - Fax:513-215-9397
Practice Address - Street 1:3301 MERCY HEALTH BLVD STE 450
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-1106
Practice Address - Country:US
Practice Address - Phone:513-347-9999
Practice Address - Fax:513-215-9397
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-0882363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0077577Medicaid
OHPA-P00919620OtherMEDICARE RR
OHPA-P00919620OtherMEDICARE RR