Provider Demographics
NPI:1114577210
Name:THIEL, JOSEPH MATTHEW
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MATTHEW
Last Name:THIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 WEST DE KOVEN
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:558 WEST DE KOVEN
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:773-706-1632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060352333146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7000Medicaid