Healthcare Provider Details

I. General information

NPI: 1326149683
Provider Name (Legal Business Name): STEPHEN CRAIG TIDWELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 10/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 BURLEYSON RD
DALTON GA
30720-3017
US

IV. Provider business mailing address

1105 BURLEYSON RD
DALTON GA
30720-3017
US

V. Phone/Fax

Practice location:
  • Phone: 706-278-4640
  • Fax: 706-275-6599
Mailing address:
  • Phone: 706-278-4640
  • Fax: 706-275-6599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number046332
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: