Provider Demographics
NPI:1972894418
Name:KIM THIELE, DO, PC
Entity type:Organization
Organization Name:KIM THIELE, DO, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:THIELE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:907-242-9000
Mailing Address - Street 1:105 TRADING BAY DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7717
Mailing Address - Country:US
Mailing Address - Phone:907-242-9000
Mailing Address - Fax:
Practice Address - Street 1:105 TRADING BAY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7717
Practice Address - Country:US
Practice Address - Phone:907-242-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4125261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD41253Medicaid
AKMD41253Medicaid