Healthcare Provider Details

I. General information

NPI: 1609851153
Provider Name (Legal Business Name): DONALD J TYNES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DON J TYNES MD

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 03/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 PIPESTONE ST
BENTON HARBOR MI
49022-4845
US

IV. Provider business mailing address

756 PIPESTONE ST
BENTON HARBOR MI
49022-4845
US

V. Phone/Fax

Practice location:
  • Phone: 269-926-8535
  • Fax: 269-926-8528
Mailing address:
  • Phone: 269-926-8535
  • Fax: 269-926-8528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301065652
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: