Healthcare Provider Details

I. General information

NPI: 1194714774
Provider Name (Legal Business Name): JEFFREY MICHAEL TIEDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 33100 BOX LANDSTUHL
APO AE
09180-3100
US

IV. Provider business mailing address

UNIT 33100 BOX LANDSTUHL
APO AE
09180-3100
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-4620
  • Fax:
Mailing address:
  • Phone: 314-590-4620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number2007032264
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: