Provider Demographics
NPI:1629141551
Name:THIELE, SCOTT ALLEN (MD)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:ALLEN
Last Name:THIELE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301050197207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1993925Medicaid
MI1605608302OtherBCBSM
MI382029531051OtherCOMMUNITY CHOICE
F05587Medicare UPIN
MIE66020003Medicare PIN