Healthcare Provider Details

I. General information

NPI: 1942837588
Provider Name (Legal Business Name): LUCAS TIDWELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26850 PROVIDENCE PKWY STE 504
NOVI MI
48374-1267
US

IV. Provider business mailing address

PO BOX 670884
DETROIT MI
48267-0884
US

V. Phone/Fax

Practice location:
  • Phone: 248-662-4333
  • Fax:
Mailing address:
  • Phone: 800-436-7936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number4301514131
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: