Healthcare Provider Details

I. General information

NPI: 1447718200
Provider Name (Legal Business Name): EMILY TIBBITTS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EMILY BLOTTER DO

II. Dates (important events)

Enumeration Date: 03/11/2019
Last Update Date: 11/30/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 482
FPO AP
96362
US

IV. Provider business mailing address

1116 ORTMAN RD
MARQUETTE MI
49855-9333
US

V. Phone/Fax

Practice location:
  • Phone: 98-971-9355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0102206313
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: