Basic Information
| Provider Information | |||||||||
| NPI: | 1992810691 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THIEL | ||||||||
| FirstName: | ADELE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019845500 | ||||||||
| FaxNumber: | 6019845503 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 RIVER OAKS DR | ||||||||
| Address2: | SUITE 420 | ||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392329500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019394198 | ||||||||
| FaxNumber: | 6019394120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 12161 | MS | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 174400000X | 12161 | MS | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 09013832 | 05 | MS | MEDICAID | 130010501 | 01 | MS | RAILROAD MEDICARE | OTHER | 0114179 | 05 | MS | MEDICAID |