Provider Demographics
NPI:1821004052
Name:THIEL, MATTHEW EUGENE (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EUGENE
Last Name:THIEL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:WYANDOT CHIROPRACTIC
Other - Middle Name:
Other - Last Name:FITNESS INC.
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CHIROPRACTOR
Mailing Address - Street 1:109 HOUPT DR
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-9201
Mailing Address - Country:US
Mailing Address - Phone:419-294-3489
Mailing Address - Fax:
Practice Address - Street 1:109 HOUPT DR
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-9201
Practice Address - Country:US
Practice Address - Phone:419-294-3489
Practice Address - Fax:419-294-2791
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1102111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311516923OtherCOMMERCIAL CLAIMS
OH311516923OtherUNITED HEALTHCARE
OH31151692300OtherBWC PROVIDER NUMBER
2882911OtherMEDICAID (GROUP)
OH5840453OtherAETNA
OH000000121332OtherANTHEM BLUE CROSS
2795088OtherMEDICAID-(INDIVIDUAL)
OH311516923OtherFEDERAL TAX ID #
OH000000121332OtherANTHEM BLUE CROSS
OH5840453OtherAETNA
2795088OtherMEDICAID-(INDIVIDUAL)