Healthcare Provider Details

I. General information

NPI: 1861553026
Provider Name (Legal Business Name): THOMAS TIETJEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 12/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 W MITCHELL ST SUITE M40
PETOSKEY MI
49770-2278
US

IV. Provider business mailing address

859 SURREY LN
PETOSKEY MI
49770-9310
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-2391
  • Fax: 231-487-6513
Mailing address:
  • Phone: 231-838-4044
  • Fax: 231-344-5923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberTT077247
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: