Provider Demographics
NPI:1548552516
Name:THELEN, TAYLOR (DO)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:THELEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 S US HIGHWAY 27
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-2423
Mailing Address - Country:US
Mailing Address - Phone:989-224-3000
Mailing Address - Fax:989-224-1424
Practice Address - Street 1:1005 S US HIGHWAY 27
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2423
Practice Address - Country:US
Practice Address - Phone:989-224-3000
Practice Address - Fax:989-224-1424
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-10
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101019134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine