Healthcare Provider Details

I. General information

NPI: 1578658670
Provider Name (Legal Business Name): THOMAS JACKSON TIDWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 WARM SPRINGS RD STE B
COLUMBUS GA
31904-7954
US

IV. Provider business mailing address

2121 WARM SPRINGS RD STE B
COLUMBUS GA
31904-7954
US

V. Phone/Fax

Practice location:
  • Phone: 706-660-8121
  • Fax: 706-323-4205
Mailing address:
  • Phone: 706-660-8121
  • Fax: 706-323-4205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License Number18964
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: