Provider Demographics
NPI:1083695522
Name:THEELE, MICHAEL GEORGE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:GEORGE
Last Name:THEELE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12752 KINGSTON PIKE
Mailing Address - Street 2:STE E202
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-0948
Mailing Address - Country:US
Mailing Address - Phone:865-777-0909
Mailing Address - Fax:865-777-0910
Practice Address - Street 1:723 BURKESVILLE HWY
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:KY
Practice Address - Zip Code:42602-1654
Practice Address - Country:US
Practice Address - Phone:865-777-0909
Practice Address - Fax:865-777-0910
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1059523367500000X
KY1102A367500000X
TN10643367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000350186OtherBLUE CROSS/BLUE SHIELD
KY74110214Medicaid
KYP00408377OtherRAILROAD MEDICARE PIN
KY0907304Medicare PIN