Healthcare Provider Details

I. General information

NPI: 1790276996
Provider Name (Legal Business Name): TERI TIDWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 CAMPUS RIDGE DR
MIDLAND MI
48640-6112
US

IV. Provider business mailing address

4742 BRIARWOOD CT
AUBURN MI
48611-8514
US

V. Phone/Fax

Practice location:
  • Phone: 989-837-9100
  • Fax: 989-837-9105
Mailing address:
  • Phone: 810-278-4599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501006181
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: