Healthcare Provider Details

I. General information

NPI: 1851037618
Provider Name (Legal Business Name): SARA TIDROW FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2022
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15125 22 MILE RD
SHELBY TOWNSHIP MI
48315-4406
US

IV. Provider business mailing address

5500 WOODMIRE DR
SHELBY TOWNSHIP MI
48316-1745
US

V. Phone/Fax

Practice location:
  • Phone: 586-532-0599
  • Fax:
Mailing address:
  • Phone: 586-216-3547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704223701
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: