Provider Demographics
NPI:1730150400
Name:TIEMAN, MICHAEL EDWARD (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:TIEMAN
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:PO BOX 1660
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-1660
Mailing Address - Country:US
Mailing Address - Phone:928-532-5463
Mailing Address - Fax:928-532-8474
Practice Address - Street 1:5171 CUB LAKE RD
Practice Address - Street 2:SUITE 280
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7866
Practice Address - Country:US
Practice Address - Phone:928-532-5463
Practice Address - Fax:928-532-8474
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ27787208600000X
WI22553208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0732060OtherBLUE CROSS BLUE SHIELD AZ
AZ478942Medicaid
AZ478942Medicaid
AZ478942Medicaid
AZAZ0732060OtherBLUE CROSS BLUE SHIELD AZ