Basic Information
| Provider Information | |||||||||
| NPI: | 1457407074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HIATT | ||||||||
| FirstName: | TADD | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 SOUTH STATE STREET | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 EAST MEDICAL CENTER DR | ||||||||
| Address2: | 3RF FLOOR TAUBMAN CENTER RECP D | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346475944 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2007 | ||||||||
| LastUpdateDate: | 12/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 46668 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0100X | 4301100152 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207R00000X | 4301100152 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | FH0879835 | 01 | CO | DEA | OTHER | 37770781 | 05 | CO | MEDICAID | FH3136226 | 01 | MI | DEA | OTHER |