MEDICARE: WILHELM TIETKE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	00007067	AL

General Provider Information

NPI Number	:	1396734661
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILHELM TIETKE MD

Provider Business Mailing Address
First Line	:	PO BOX 2324
Second Line	:
City	:	BIRMINGHAM
State	:	AL
Zip	:	35201-2324
Country	:	US
Telephone Number	:	256-533-6488
Fax Number	:	256-533-6495

Provider Business Practice Location Address
First Line	:	119 LONGWOOD DR
Second Line	:
City	:	HUNTSVILLE
State	:	AL
Zip	:	35801
Country	:	US
Telephone Number	:	256-533-6488
Fax Number	:	256-533-6495

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/19/2005
Last Update Date	:	07/08/2007

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