MEDICARE: DR. DONALD J TYNES M.D.

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	207R00000X	Internal Medicine Physician	4301065652	MI

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	OPO3540	OTHER	MI	MEDICARE GROUP BUSINESS NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	06103A	OTHER	MI	BERRIEN HEALTH PLAN
2	7338232	OTHER	MI	AETNA
3	11-01-11-04-82	OTHER	MI	BCBS
5	11583	OTHER	MI	HEATH PLAN OF MICHIGAN
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
7	412153406100	OTHER	MI	COMMUNITY CHOICE OF MI

General Provider Information

NPI Number	:	1609851153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DONALD J TYNES M.D.

Provider Business Mailing Address
First Line	:	756 PIPESTONE ST
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-4845
Country	:	US
Telephone Number	:	269-926-8535
Fax Number	:	269-926-8528

Provider Business Practice Location Address
First Line	:	756 PIPESTONE ST
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-4845
Country	:	US
Telephone Number	:	269-926-8535
Fax Number	:	269-926-8528

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	03/20/2019

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