Healthcare Provider Details

I. General information

NPI: 1598826521
Provider Name (Legal Business Name): THOMAS GIETZEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W MITCHELL ST SUITE G40
PETOSKEY MI
49770-2275
US

IV. Provider business mailing address

4100 PARK FOREST DR SUITE 208
TRAVERSE CITY MI
49684-7331
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-2391
  • Fax: 231-487-6513
Mailing address:
  • Phone: 231-935-9060
  • Fax: 231-935-9055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberTG030269
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: