Provider Demographics
NPI:1659509701
Name:TIERNEY, MARK T (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:TIERNEY
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 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9686
Mailing Address - Country:US
Mailing Address - Phone:616-252-7159
Mailing Address - Fax:
Practice Address - Street 1:5900 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519
Practice Address - Country:US
Practice Address - Phone:616-252-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010947952085R0202X
IN01079373A2085R0202X
WI619842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology