Healthcare Provider Details

I. General information

NPI: 1659360808
Provider Name (Legal Business Name): RANDY T THEILER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 E BROOKLYN ST
CHILTON WI
53014-1595
US

IV. Provider business mailing address

451 E BROOKLYN ST
CHILTON WI
53014-1595
US

V. Phone/Fax

Practice location:
  • Phone: 920-849-9375
  • Fax:
Mailing address:
  • Phone: 920-849-9375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21872
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: