MEDICARE: MICHAEL TICHY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1023545969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL TICHY

Provider Business Mailing Address
First Line	:	2730 SW MOODY AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97201-5042
Country	:	US
Telephone Number	:	503-494-8867
Fax Number	:

Provider Business Practice Location Address
First Line	:	1353 EDGEWATER ST NW
Second Line	:
City	:	SALEM
State	:	OR
Zip	:	97304-4050
Country	:	US
Telephone Number	:	503-378-0466
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/22/2017
Last Update Date	:	05/22/2017

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