=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588658702
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WARREN STUART THEIS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2005
-----------------------------------------------------
Last Update Date | 06/03/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1405 ALICE ST
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31501-4528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-285-8822
-----------------------------------------------------
Fax | 912-285-8898
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1405 ALICE ST
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31501-4528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-285-8822
-----------------------------------------------------
Fax | 912-285-8898
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 055345
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 0101237160
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A84102
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | ME96329
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------