Healthcare Provider Details

I. General information

NPI: 1215165014
Provider Name (Legal Business Name): MICHAEL JOHN TIQUI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 01/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRAND ST
NEW BRITAIN CT
06052-2016
US

IV. Provider business mailing address

100 GRAND ST
NEW BRITAIN CT
06052-2016
US

V. Phone/Fax

Practice location:
  • Phone: 860-224-5771
  • Fax:
Mailing address:
  • Phone: 860-224-5771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301094887
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number050746
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: