Healthcare Provider Details

I. General information

NPI: 1639039936
Provider Name (Legal Business Name): MICHAEL THOMAS PIESCHEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT ELIZABETH BLVD # 3000
O FALLON IL
62269-1099
US

IV. Provider business mailing address

397 BLUE BIRD LN
TROY IL
62294-2109
US

V. Phone/Fax

Practice location:
  • Phone: 618-234-2120
  • Fax:
Mailing address:
  • Phone: 218-349-3727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number209.033858
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: