Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 4301108689 | MI |
N | 111NI0900X | Internist | 4301108689 | MI |
Y | 207RC0200X | Critical Care Medicine | 4301108689 | MI |
N | 207RC0200X | Critical Care Medicine | 6606 | ND |
NPI | 1003838681 |
---|---|
Provider Name | Mark J Tieszen |
First Address | Wyoming, MI 49519-9606 |
Second Address | Wyoming, MI 49519-9606 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2006 |
Last Update Date | 17/03/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
E52434 | (02) |