Healthcare Provider Details

I. General information

NPI: 1093086563
Provider Name (Legal Business Name): PAT T. TIDWELL MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2012
Last Update Date: 12/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4554 HIGHWAY 20 EAST
NICEVILLE FL
32578
US

IV. Provider business mailing address

4554 HIGHWAY 20 EAST
NICEVILLE FL
32578
US

V. Phone/Fax

Practice location:
  • Phone: 850-678-6735
  • Fax: 850-678-8078
Mailing address:
  • Phone: 850-678-6735
  • Fax: 850-678-8078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberME30890
License Number StateFL

VIII. Authorized Official

Name: MR. PAT THOMAS TIDWELL SR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 850-678-6735