Provider Demographics
NPI:1801875679
Name:TIESENGA, FREDERICK M (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:M
Last Name:TIESENGA
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 1:1950 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60707
Mailing Address - Country:US
Mailing Address - Phone:708-453-6800
Mailing Address - Fax:708-453-3985
Practice Address - Street 1:1950 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:IL
Practice Address - Zip Code:60707-3717
Practice Address - Country:US
Practice Address - Phone:708-453-6800
Practice Address - Fax:708-453-3235
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36086475208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL390720OtherMEDICARE
IL36086475Medicaid
IL390720OtherMEDICARE
IL390720Medicare ID - Type Unspecified