Basic Information
| Provider Information | |||||||||
| NPI: | 1467486829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIETZ | ||||||||
| FirstName: | FREDRIC | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6096 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977086096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415488131 | ||||||||
| FaxNumber: | 5417063765 | ||||||||
| Practice Location | |||||||||
| Address1: | 1253 NW CANAL BLVD | ||||||||
| Address2: | ST. CHARLES MEDICAL CENTER REDMOND | ||||||||
| City: | REDMOND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415488131 | ||||||||
| FaxNumber: | 5417063765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 04/23/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G50497 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD166601 | OR | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.