Provider Demographics
NPI:1043361629
Name:THIELE, KIM EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:EDWARD
Last Name:THIELE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36901 MALLARD RD
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-6434
Mailing Address - Country:US
Mailing Address - Phone:907-283-5000
Mailing Address - Fax:
Practice Address - Street 1:36901 MALLARD RD
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-6434
Practice Address - Country:US
Practice Address - Phone:907-283-5000
Practice Address - Fax:907-283-5013
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMEDO4125207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1013951Medicaid