Provider Demographics
NPI:1902023641
Name:BRIAN T. GIETZEN, M. D., P. C.
Entity Type:Organization
Organization Name:BRIAN T. GIETZEN, M. D., P. C.
Other - Org Name:LEGACY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:GIETZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-650-1800
Mailing Address - Street 1:1460 WALTON BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1768
Mailing Address - Country:US
Mailing Address - Phone:248-650-1800
Mailing Address - Fax:248-650-1856
Practice Address - Street 1:1460 WALTON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1768
Practice Address - Country:US
Practice Address - Phone:248-650-1800
Practice Address - Fax:248-650-1856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070159207R00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIH51538Medicare UPIN
MI0P22110Medicare ID - Type Unspecified