Basic Information
| Provider Information | |||||||||
| NPI: | 1679578637 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIEDEMAN | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 36070 | ||||||||
| Address2: | |||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297320500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033245256 | ||||||||
| FaxNumber: | 8033280440 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721-07 EBENEZER ROAD | ||||||||
| Address2: | SUITE 175 | ||||||||
| City: | ROCK HILL | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8033245256 | ||||||||
| FaxNumber: | 8033280440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 04840 | SC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 048406 | 05 | SC | MEDICAID | 297389 | 01 | MAMSI | OTHER | 2073884 | 01 | FIRST HEALTH | OTHER |