1568535938 NPI number — PAUL O THIEME JR. DO

Table of content: PAUL O THIEME JR. DO (NPI 1568535938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568535938 NPI number — PAUL O THIEME JR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THIEME
Provider First Name:
PAUL
Provider Middle Name:
O
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
DO
Provider Gender Code:
M

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:
1568535938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1895 M 28 E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARQUETTE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49855-9546
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-249-4942
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 W MAGNETIC STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARQUETTE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-228-9440
Provider Business Practice Location Address Fax Number:
906-225-3772
Provider Enumeration Date:
11/15/2006

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: 2085R0001X , with the licence number:  010272 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4565403 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".