Basic Information
| Provider Information | |||||||||
| NPI: | 1083695522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THEELE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12752 KINGSTON PIKE | ||||||||
| Address2: | STE E202 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379340948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657770909 | ||||||||
| FaxNumber: | 8657770910 | ||||||||
| Practice Location | |||||||||
| Address1: | 723 BURKESVILLE HWY | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426021654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8657770909 | ||||||||
| FaxNumber: | 8657770910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 01/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1059523 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 1102A | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 10643 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 000000350186 | 01 | KY | BLUE CROSS/BLUE SHIELD | OTHER | 74110214 | 05 | KY | MEDICAID | P00408377 | 01 | KY | RAILROAD MEDICARE PIN | OTHER |