Provider Demographics
NPI:1538151212
Name:TINNEY, RODERIC E (MD)
Entity type:Individual
Prefix:DR
First Name:RODERIC
Middle Name:E
Last Name:TINNEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14734 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1927
Mailing Address - Country:US
Mailing Address - Phone:231-547-6554
Mailing Address - Fax:231-547-1179
Practice Address - Street 1:14734 PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1927
Practice Address - Country:US
Practice Address - Phone:231-547-6554
Practice Address - Fax:231-547-1179
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRT 046881208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3495977Medicaid
MI3495977Medicaid