Provider Demographics
NPI:1033101225
Name:TIEN, TUDOR R (MD)
Entity Type:Individual
Prefix:DR
First Name:TUDOR
Middle Name:R
Last Name:TIEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TUDOR
Other - Middle Name:R
Other - Last Name:TIEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPARTMENT 272801
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:517-841-1431
Mailing Address - Fax:517-841-1432
Practice Address - Street 1:1201 E MICHIGAN AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1852
Practice Address - Country:US
Practice Address - Phone:517-841-1431
Practice Address - Fax:517-841-1432
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-12-16
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-27
Provider Licenses
StateLicense IDTaxonomies
MI4301084403174400000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0920018OtherPHYSICIALS HEALTH PLAN
MI5392560001OtherMEDICARE DMERC
MI2003810541OtherBLUE CROSS BLUE SHIELD MI
MAP118495OtherBLUE CARE NETWORK
MI700C810580OtherBC - FOOTE
MI700C810580OtherBC - FOOTE
MI5392560001OtherMEDICARE DMERC
MII16878Medicare UPIN
MI437004210Medicare ID - Type Unspecified