Healthcare Provider Details

I. General information

NPI: 1093717506
Provider Name (Legal Business Name): JOHN E THIEL JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2095 HENRY TECKLENBURG DR
CHARLESTON SC
29414-5733
US

IV. Provider business mailing address

2901 MIDDLE ST
SULLIVANS ISLAND SC
29482-8644
US

V. Phone/Fax

Practice location:
  • Phone: 843-452-7205
  • Fax:
Mailing address:
  • Phone: 843-452-7205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR58231
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: