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General NPI Number Information
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NPI Number | 1518360916
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Entity Type | Organization
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Legal Business Name | TOM TIETJEN MD PLLC
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Dates
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Enumeration Date | 09/30/2014
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Last Update Date | 12/12/2014
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Provider Practice Location Address
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Address Line | 267 CREEKSIDE DR SUITE 200
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City | PETOSKEY
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State | MI
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Zip | 49770-7609
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Country | US
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Telephone | 231-753-2105
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Fax | 231-344-5923
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Provider Business Mailing Address
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Address Line | 859 SURREY LN
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City | PETOSKEY
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State | MI
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Zip | 49770-9310
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Country | US
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Telephone | 231-439-5491
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. THOMAS TIETJEN
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Credential | MD
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Telephone | 231-439-5491
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number | 4301077247
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License Number State | MI
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