Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN0400X | Neurology | #X009619 | NY |
Y | 111NN0400X | Neurology | 4227-012 | WI |
NPI | 1649327784 |
---|---|
Provider Name | Dr. Scott M Theirl |
First Address | Thiensville, WI 53092-1713 |
Second Address | Mequon, WI 53092-3377 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2007 |
Last Update Date | 04/04/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
#U79534 | (02) | NY |
WI1690 | MEDICARE PTAN (01) | WI |