Provider Demographics
NPI:1598826521
Name:GIETZEN, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:GIETZEN
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 1:4100 PARK FOREST DR
Mailing Address - Street 2:SUITE 208
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7331
Mailing Address - Country:US
Mailing Address - Phone:231-935-9060
Mailing Address - Fax:231-935-9055
Practice Address - Street 1:560 W MITCHELL ST
Practice Address - Street 2:SUITE G40
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2275
Practice Address - Country:US
Practice Address - Phone:231-487-2391
Practice Address - Fax:231-487-6513
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MITG030269207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4109215Medicaid
MIOB81010OtherBCBSM
MIB43713Medicare UPIN