Provider Demographics
NPI:1912352873
Name:THIEL, GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:
Last Name:THIEL
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:PO BOX 312
Mailing Address - Street 2:
Mailing Address - City:PEMBINE
Mailing Address - State:WI
Mailing Address - Zip Code:54156-0312
Mailing Address - Country:US
Mailing Address - Phone:715-324-6019
Mailing Address - Fax:
Practice Address - Street 1:N20015 ECHO LAKE RD
Practice Address - Street 2:
Practice Address - City:NIAGRA
Practice Address - State:WI
Practice Address - Zip Code:54151
Practice Address - Country:US
Practice Address - Phone:715-324-6019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI25458207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine