Provider Demographics
NPI:1861553026
Name:TIETJEN, THOMAS (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:TIETJEN
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 1:859 SURREY LN
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9310
Mailing Address - Country:US
Mailing Address - Phone:231-838-4044
Mailing Address - Fax:231-344-5923
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE M40
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2278
Practice Address - Country:US
Practice Address - Phone:231-487-2391
Practice Address - Fax:231-487-6513
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MITT077247207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861553026Medicaid
MIE82211Medicare UPIN