Basic Information
Provider Information | |||||||||
NPI: | 1306839949 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TIEDE | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1200 SIXTH AVE N | ||||||||
Address2: | CENTRACARE CLINIC | ||||||||
City: | ST CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563032735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202525131 | ||||||||
FaxNumber: | 3202402118 | ||||||||
Practice Location | |||||||||
Address1: | 1200 SIXTH AVE N | ||||||||
Address2: | CENTRACARE CLINIC | ||||||||
City: | ST CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563032735 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202525131 | ||||||||
FaxNumber: | 3202402118 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2005 | ||||||||
LastUpdateDate: | 07/31/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35523 | MN | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | 35523 | MN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 852362200 | 01 |   | MEDICAL ASSISTANCE (MA) | OTHER | 852362200 | 05 | MN |   | MEDICAID | HP31427 | 01 |   | HEALTH PARTNERS | OTHER | 95D80T1 | 01 |   | BCBS | OTHER | 1025405 | 01 |   | PREFERRED ONE | OTHER | 1119213 | 01 |   | ARAZ GROUP/AMERICA'S PPO | OTHER | 2114057 | 01 |   | FIRST HEALTH PLAN | OTHER | 119337 | 01 |   | U-CARE | OTHER | 2500414 | 01 |   | MEDICA HEALTH PLANS | OTHER |