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General NPI Number Information
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NPI Number | 1316158173
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Entity Type | Organization
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Legal Business Name | CHARLES A TIETZ MD FACOG LTD
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Dates
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Enumeration Date | 05/24/2007
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Last Update Date | 01/14/2008
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Provider Practice Location Address
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Address Line | 307 1ST ST S STE108
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City | VIRGINIA
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State | MN
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Zip | 55792-2696
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Country | US
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Telephone | 218-749-8326
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Fax | 218-749-8608
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Provider Business Mailing Address
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Address Line | 307 1ST ST S STE 108
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City | VIRGINIA
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State | MN
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Zip | 55792-2696
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Country | US
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Telephone | 218-749-8326
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Fax | 218-749-8608
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | POLLY LALONDE
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Credential |
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Telephone | 218-749-8326
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | 1287
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License Number State | MN
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