Provider Demographics
NPI:1821375940
Name:MARK TIEMAN, MD, PC
Entity Type:Organization
Organization Name:MARK TIEMAN, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:DARYL
Authorized Official - Last Name:TIEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-424-9844
Mailing Address - Street 1:34 COPPERDALE LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2523
Mailing Address - Country:US
Mailing Address - Phone:631-424-9844
Mailing Address - Fax:631-543-2785
Practice Address - Street 1:356 VETERANS MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-4343
Practice Address - Country:US
Practice Address - Phone:631-858-0400
Practice Address - Fax:631-543-2785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY179172261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care