Healthcare Provider Details

I. General information

NPI: 1578528436
Provider Name (Legal Business Name): ROCK GERARD TIFFAULT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 S CREASY LN
LAFAYETTE IN
47905-4972
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 765-423-6165
  • Fax: 765-502-4683
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL1219
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01056196A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01056196A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39496
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberL1219
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: