Provider Demographics
NPI:1407834898
Name:TEGTMEYER, LOUIS CHARLES (DO)
Entity Type:Individual
Prefix:DR
First Name:LOUIS
Middle Name:CHARLES
Last Name:TEGTMEYER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3799 MOMENTUM PLACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5337
Mailing Address - Country:US
Mailing Address - Phone:231-876-3876
Mailing Address - Fax:231-775-1115
Practice Address - Street 1:927 S CARMEL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2547
Practice Address - Country:US
Practice Address - Phone:231-876-3876
Practice Address - Fax:231-775-1115
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208600000X208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3331910Medicaid
MI3331910Medicaid
MI0M34020Medicare PIN