Provider Demographics
NPI:1356717896
Name:STEILS, THEODORE
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:STEILS
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:PO BOX 265
Mailing Address - Street 2:BROOKWOOD SECURE CENTER
Mailing Address - City:CLAVERACK
Mailing Address - State:NY
Mailing Address - Zip Code:12513-0265
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:419 SPOOK ROCK RD
Practice Address - Street 2:
Practice Address - City:CLAVERACK
Practice Address - State:NY
Practice Address - Zip Code:12513
Practice Address - Country:US
Practice Address - Phone:518-851-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005654363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant