Basic Information
| Provider Information | |||||||||
| NPI: | 1386649465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TINNES | ||||||||
| FirstName: | GARRY | ||||||||
| MiddleName: | D | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474033239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123553299 | ||||||||
| FaxNumber: | 8123553290 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474033239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123553299 | ||||||||
| FaxNumber: | 8123553290 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 12/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 01043109A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200469400 | 05 | IN | MEDICAID |