Healthcare Provider Details

I. General information

NPI: 1538149216
Provider Name (Legal Business Name): STEVEN M TIDWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5155 CORPORATE WAY STE A
JUPITER FL
33458-4359
US

IV. Provider business mailing address

52 SAINT THOMAS DR
PALM BEACH GARDENS FL
33418-4598
US

V. Phone/Fax

Practice location:
  • Phone: 561-624-0123
  • Fax: 561-624-1453
Mailing address:
  • Phone: 561-625-1626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME 62477
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: