Healthcare Provider Details

I. General information

NPI: 1598153652
Provider Name (Legal Business Name): TIDWELL HEALTH SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2014
Last Update Date: 12/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4435 SPAHN ST
SARASOTA FL
34232-5135
US

IV. Provider business mailing address

4435 SPAHN ST
SARASOTA FL
34232-5135
US

V. Phone/Fax

Practice location:
  • Phone: 941-726-2082
  • Fax:
Mailing address:
  • Phone: 941-726-2082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9326689
License Number StateFL

VIII. Authorized Official

Name: DOUGLAS JAY TIDWELL
Title or Position: OWNER/PRESIDENT
Credential: ARNP
Phone: 941-726-2082