Healthcare Provider Details

I. General information

NPI: 1104816719
Provider Name (Legal Business Name): ALBERT E THIELEN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 SHAKER ROAD
EAST LONGMEADOW MA
01028-1838
US

IV. Provider business mailing address

354 BIRNIE AVE HAMPDEN COUNTY PHYSICIAN ASSOCIATES
SPRINGFIELD MA
01107-1108
US

V. Phone/Fax

Practice location:
  • Phone: 413-525-3958
  • Fax: 413-525-3943
Mailing address:
  • Phone: 413-733-3470
  • Fax: 413-733-5235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number36175
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: