Provider Demographics
NPI:1417204686
Name:WILHELM TIETKE MD PC
Entity Type:Organization
Organization Name:WILHELM TIETKE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILHELM
Authorized Official - Middle Name:
Authorized Official - Last Name:TIETKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-880-9628
Mailing Address - Street 1:131 LONGWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-4522
Mailing Address - Country:US
Mailing Address - Phone:256-880-9628
Mailing Address - Fax:256-880-9629
Practice Address - Street 1:131 LONGWOOD DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4522
Practice Address - Country:US
Practice Address - Phone:256-880-9628
Practice Address - Fax:256-880-9629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL7067207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty