Provider Demographics
NPI:1346313277
Name:MIDMICHIGAN OBSTETRICS AND GYNECOLOGY P C
Entity Type:Organization
Organization Name:MIDMICHIGAN OBSTETRICS AND GYNECOLOGY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:THIELE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-631-6730
Mailing Address - Street 1:3016 W WACKERLY ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6160
Mailing Address - Country:US
Mailing Address - Phone:989-631-6730
Mailing Address - Fax:989-631-4968
Practice Address - Street 1:3016 W WACKERLY ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6160
Practice Address - Country:US
Practice Address - Phone:989-631-6730
Practice Address - Fax:989-631-4968
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050197207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E660200OtherBCBSM
MI0E660200OtherBCBSM