Healthcare Provider Details

I. General information

NPI: 1801875679
Provider Name (Legal Business Name): FREDERICK M TIESENGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 N HARLEM AVE
ELMWOOD PARK IL
60707-3717
US

IV. Provider business mailing address

1950 N HARLEM AVE
ELMWOOD PARK IL
60707
US

V. Phone/Fax

Practice location:
  • Phone: 708-453-6800
  • Fax: 708-453-3235
Mailing address:
  • Phone: 708-453-6800
  • Fax: 708-453-3985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number36086475
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: