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NPI Code Detail

MEDICARE: STEPHEN ROBERT TISDALE MSPAS, PA-C

MEDICARE: STEPHEN ROBERT TISDALE MSPAS, PA-C
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
1363A00000XPhysician Assistant5601008212MI
2363A00000XPhysician Assistant50.008487RXOH

General Provider Information

NPI Number : 1790212728
Entity Type Code : Individual
Provider Name (Legal Business Name) : STEPHEN ROBERT TISDALE MSPAS, PA-C
Provider Business Mailing Address
First Line : 16925 WATERLOO RD
Second Line :
City : CHELSEA
State : MI
Zip : 48118-9021
Country : US
Telephone Number : 734-368-7025
Fax Number :
Provider Business Practice Location Address
First Line : 2865 N REYNOLDS RD BLDG A
Second Line :
City : TOLEDO
State : OH
Zip : 43615-2100
Country : US
Telephone Number : 419-578-7200
Fax Number : 419-537-5600
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/22/2017
Last Update Date : 11/21/2023

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