MEDICARE: DR. DETRA MICHELLE TISDALE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	053713	GA
2	207R00000X	Internal Medicine Physician	MD202661	LA
3	207R00000X	Internal Medicine Physician	46435	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730273079
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DETRA MICHELLE TISDALE M.D.

Provider Business Mailing Address
First Line	:	1144 N HOUSTON LEVEE RD
Second Line	:	SUITE 102
City	:	CORDOVA
State	:	TN
Zip	:	38018-7145
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1144 N HOUSTON LEVEE RD
Second Line	:	SUITE 102
City	:	CORDOVA
State	:	TN
Zip	:	38018-7145
Country	:	US
Telephone Number	:	901-382-2044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	12/06/2010

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