MEDICARE: GEORGIA TIBBITTS D.O.

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	207P00000X	Emergency Medicine Physician	5101014022	MI

General Provider Information

NPI Number	:	1154788255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GEORGIA TIBBITTS D.O.

Provider Business Mailing Address
First Line	:	17700 23 MILE RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48044-1154
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17700 23 MILE RD
Second Line	:
City	:	MACOMB
State	:	MI
Zip	:	48044-1154
Country	:	US
Telephone Number	:	586-416-7520
Fax Number	:

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

Provider Enumeration Date	:	01/20/2016
Last Update Date	:	12/06/2016

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Directions to “ GEORGIA TIBBITTS D.O.” Practice Location

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